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A

SYSTEM OF MEDICINE
BASED UPON THE
3-8719
LAW OF HOMOEOPATHY.
EDITED BY
H. R. ARNDT, M.D.
IN THREE VOLUMES.
VOL. I.
PHILADELPHIA :
HAHNEMANN PUBLISHING HOUSE,
F. E. BOERICKE.
1885.
፡
Copyrighted, 1885, by F. E. BOERICKE.
SHERMAN & Co., PRINTERS, PHILADA.
PREFACE.
IN
In presenting to the homoeopathic branch of the medical
profession the "SYSTEM OF MEDICINE, BASED UPON THE LAW
OF HOMOEOPATHY," the general editor experiences an amount
of trepidation which is quite as great as were the enthusiasm
and confidence with which he, in the spring of 1882, com-
menced the task of preparing this work. After nearly three
years of unceasing toil, of constant anxiety, and of endless cor-
respondence, he at last submits the completed work to the
criticism of his colleagues, trusting that the judgment to be
passed upon it will be based not only upon justice but upon
generosity also.
The editor possesses one great advantage over the majority
of the progenitors of new books in that he needs not enlarge
upon the raison d'être of this publication. The entire homoeo-
pathic school have, for years, experienced the want of a work
on "Practice" which should take the place of the very excel-
lent, but now old, treatises of Baehr, Kafka, and others. It
was justly argued that none of these works are sufficiently
comprehensive to serve our students as a satisfactory text-
book, or our practitioners as a reliable guide for consultation
and a safe authority in times of perplexity and doubt. In the
course of time the matter was brought to the notice of the
publishers and of medical men likely to be especially interested
in an undertaking of this nature. To the general consciousness
of a want which, it was evident, must be supplied soon, and to
the agitations of medical gentlemen in various parts of our
common country-among whom our friend, Dr. C. E. Fisher,
of Texas, was particularly active-is due, in a large measure,
the preparation of this work.
Since the general editor alone is responsible for the plan of
this work, for the arrangement of its contents, for the limitation
8
PREFACE.
of its scope, and for the character of its teaching, so far as it
bears on homœopathic practice, whatever fault may be found
with these must of necessity be laid at his door. Aside from
these, each contributor is wholly responsible for the articles
which constitute his contributions to this work.
The list of contributors embraces many of our ablest writers
and teachers, and, in the aggregate, represents a very large
amount of special study and valuable clinical experience. The
desire to secure the active coöperation of physicians particularly
qualified to speak with authority on the various topics of ab-
sorbing interest to the medical practitioner involved a laborious
correspondence and a considerable delay in the appearance of
this work. It is a source of the greatest satisfaction to know
that this delay, however annoying in some respects, has made
it possible for many of the over-worked men in the profession
to contribute from the wealth of their large experience as
general practitioners or specialists, an important feature of this
work which under other circumstances could not have been
maintained. To utilize fully the value of the clinical experience
of each contributor, no restraint has been placed upon the
members of the editorial corps outside of the observance of
such general rules as were necessary to insure a desirable unity
of the entire work. In each instance, then, the reader has
placed before him the result of actual experience gained by
observation at the bedside, a feature of the work which becomes
of great importance in those portions which deal with the treat-
ment of special pathological conditions.
After a careful examination of the various methods of ar-
rangement of contents employed by different authors, the editor
adopted the general grouping of Reynolds, subdividing, how-
ever, each section upon an anatomical basis. Thus, the section
upon Diseases of the Organs of Digestion is divided into dis-
eases of the mouth, oesophagus, stomach, intestines, peritoneum,
liver, and pancreas; each of these is again similarly subdivided.
Thus, the Diseases of the Mouth are treated in the following
order: diseases of the gums, teeth, tongue, salivary glands,
tonsils, uvula, mucous membrane of the mouth.
921
PREFACE.
9
The treatment of each topic is based upon a desire to make
every chapter of the greatest possible value to the reader. It
has been the aim of contributors to give just enough space to
ætiology, pathology, differential diagnosis, and so forth, to make
the article complete, and to furnish a clear summing-up of the
present status of pathological knowledge and of the subjects
enumerated. The limited space, however, at our disposal, and
the firm determination to avoid theoretical and speculative
matter, have resulted in the comparative brevity of some
chapters devoted to the discussion of subjects which are fre-
quently considered at great length in similar works of the
dominant school of medicine. No matter what criticism may
be offered here, it is thought that this feature will, upon the
whole, prove acceptable.
Particular pains have been taken with the "treatment" of
the various diseases herein discussed. The remedies, in most
cases, have been arranged not alphabetically, as has been the
custom, but in the order of their clinical importance. This
arrangement is not free from objection, because remedies which
a writer deems of paramount importance in the treatment of
some one disorder, may to the professional reader seem of
little value in the same condition, and vice versa. Such re-
sult is unavoidable in a work of this kind, and readers may
take consolation from the fact that the work has been done
not only conscientiously but, in nearly all cases, by those
abundantly qualified by extensive clinical experience to speak
with authority.
The indications for remedies are of necessity given with
reference only to symptoms which occur in direct connection
with the disorders treated; concomitant symptoms usually are
ignored, because a work like this cannot be made to take the
place of a work on symptomatology. In order to further in-
crease the usefulness of this work, the chapters on "treatment"
were not limited in range to therapeutics, but were made to
embrace extensive observations on hygiene, nursing, dietetics,
the use of hot and cold baths, electro-therapeutics, and the
various means and agencies with which the intelligent medical
10
PREFACE.
man at this day combats disease and relieves suffering. The
information thus furnished, and the directions here given, do
not in the least compromise the dignity and the clinical value.
of the homoeopathic law, but represent the homeopathic prac-
tice of to-day as it really exists, and will prove the means
of saving our younger colleagues much anxiety and possible
blundering; these considerations will more than outweigh any
criticism which can be offered on this score.
When first outlining the plan for this work, it was intended
to have appended to each chapter the full bibliography of the
subject therein treated. As the work progressed, it became
evident that space must be closely economized, and, although
the original size of the work was enlarged by the addition of a
third volume, it has been impossible to carry out a custom
which, in more than one respect, commends itself to the readers
of scientific works. For the same reason, the large number of
illustrations generally, and often unnecessarily, introduced into
works of this kind was limited to a few excellent cuts really
indispensable to the understanding of the topic which they
illustrate.
To the members of the editorial staff the general editor
wishes to express his appreciation of the readiness and patience
with which they have seconded his efforts to insure for this
work a sphere of the largest possible usefulness; to their kindly
support is due whatever success and friendly criticism these
volumes may meet.
Fully aware of the unavoidable imperfections of this work,
the general editor yet fondly hopes that the unceasing labor
of three years has not been in vain, and that these clean new
pages will, before long, show the marks of that wear and tear
which are a practical proof of the real usefulness of a publica-
tion like this.
GRAND RAPIDS, MICH., February 1st, 1885.
H. R. ARNDT.
CONTENTS OF VOLUME I.
INTRODUCTORY CHAPTER. By the General Editor,
page 17
CHAPTER ON PHYSICAL DIAGNOSIS. By Herbert C. Clapp, M.D., 44
REGIONS OF THE CHEST AND ABDOMEN, 45. PHYSICAL EXAMINATION
OF THE LUNGS, 48 (inspection, 49; mensuration, 49; palpation,
50; succussion, 50; percussion, 51; percussion of the healthy
chest, 51; percussion in disease, 52; auscultation, 53; respira-
tion in health, 54; respiration in disease, 54; altered intensity,
54; altered rhythm, 55; altered quality and pitch, 55; dry râles,
56; moist râles, 57; pleuritic friction-sounds, 58; the voice in
health, 58; the voice in disease, 58). PHYSICAL EXAMINATION
OF THE HEART AND OF AORTIC ANEURISM, 60 (inspection, 60;
palpation, 61; percussion, 61; auscultation, 61; murmurs or
adventitious heart-sounds, 63; pericardial friction-sounds, 64;
endocardial murmurs, 64; anæmic heart-murmurs, 64; organic
heart-murmurs, 64). PHYSICAL EXAMINATION OF THE LARYNX,
67 (artificial illumination, 67; method of examination, 68;
laryngeal image in health, 69; normal color of the parts, 70).
PHYSICAL EXAMINATION OF THE NARES, 71 (the use of the mirror,
71; the use of the tongue-depressor, 72; anterior rhinoscopy, 72;
exploration with finger and probes, 73). PHYSICAL EXAMINA-
TION OF THE ABDOMEN, 73 (inspection, 74; mensuration and pal-
pation, 76; palpation of the liver, 77; palpation of the gall-
bladder, 77; palpation of the spleen and of the stomach, 78;
palpation of the intestines, 79; palpation in ascites, 80; pal-
pation of the kidneys, 81; palpation of the bladder and of
the uterus, 82; palpation of the ovaries, 84; palpation of ab-
dominal aneurism, 85; percussion of the abdomen and liver,
85; percussion of the spleen, 87; percussion of the stomach,
88; percussion of the intestines and of ascites, 89; percussion
of the kidneys, bladder, uterus, 90; percussion of ovarian tumor,
91; auscultation of the abdomen, stomach, intestines, pregnant
uterus, 91; fœtal pulsation, 91; uterine souffle, 92; ausculta-
tion of abdominal aneurism, 93). PHYSICAL EXAMINATION OF
THE URINE, 93 (quantity, color, reaction, 94; specific gravity, 95;
urea and the urates, 96; phosphates, chlorides, albumen, 97;
sugar in the urine, 98; blood in the urine, 99; mucus, pus, tube-
casts, 100).
12
CONTENTS.
LOCAL DISEASES.
DISEASES OF THE RESPIRATORY ORGANS.
ɑ. DISEASES OF THE NASAL CAVITY.
BY LUCIUS D. MORSE, M.D.
Acute catarrh or coryza, 102; chronic catarrh, 110; ozæna, 120;
syphilitic affections of the nasal cavity, 123; hay-fever, 124;
epistaxis, 128; tumors of the nasal cavity, 132; abscess of the
nasal cavity, 134; foreign bodies in the nasal cavity, 135.
b. DISEASES OF THE LARYNX.
BY JOSEPH SIDNEY MITCHELL, M.D.
Acute catarrhal laryngitis, 135; œdema glottidis, 138; chronic laryn-
gitis, 139; perichondritis laryngis, 142; laryngeal phthisis, 142;
syphilitic laryngitis, 147; neuroses of the larynx, 147 (unilateral
paralysis of the adductor of one vocal cord, 148; bilateral par-
alysis of the adductors of the vocal cords, 149; unilateral
paralysis of the abductor of one cord, 149; bilateral paralysis
of the abductors of the vocal cords, 150; paralysis of the thyro-
arytenoid muscles, 151; laryngismus stridulus, 152); diseases of
the sensory system of the larynx, 154; tumors of the larynx, 155;
croup, 159.
C. DISEASES OF THE TRACHEA AND BRONCHIA.
BY JOSEPH SIDNEY MITCHELL, M.D.
Bronchitis, 173 (acute catarrhal, 173; capillary, 177; chronic, 185;
dry catarrh, 186; bronchorrhoea, 186; fetid bronchitis, 187; croup-
ous, 190); bronchial asthma, 192.
d. DISEASES OF THE PARENCHYMA OF THE LUNGS.
Pneumonia. By A. K. CRAWFORD, M.D., 202 (acute lobar, croupous,
204; lobular pneumonia, or broncho-pneumonia, 215). Phthisis
pulmonalis. By HERBERT C. CLAPP, M.D., 220 (the contagious-
ness of consumption, 221; predisposition, 228; predisposing
causes, 230; pathological anatomy, 233; cascous or catarrhal
phthisis, 236; fibroid phthisis, 237; physical signs, 239; symp-
toms, 241; varieties, 249; differential diagnosis, 251 [from chronic.
bronchitis, 251; from chronic pleurisy, 251; from pneumonia,
252; from pulmonary cancer, 252; from pulmonary syphilis, 252;
from pulmonary abscess, gangrene, bronchial dilatation, 253];
the diagnostic value of the bacilli tuberculosis, 254; methods
used for the detection of the bacilli tuberculosis, 255; prognosis,
258; treatment, 260; prophylaxis, 262; hygienic treatment, 263;
climatic treatment, 267; therapeutics, 274). Pulmonary conges-
tion, œdema, hæmorrhage, and apoplexy. By A. K. CRAWFORD,
CONTENTS.
13
M.D., 278. Emphysema pulmonum. By A. K. CRAWFORD, M.D.,
285. Apneumatosis, atelectasis pulmonum. By A. K. CRAWFORD,
M.D., 290. Pulmonary gangrene. By A. K. CRAWFORD, M.D., 294.
Syphilitic diseases of the lungs. By W. B. TRITES, M.D., 295.
Cancer of the lungs. By H. R. ARNDT, M.D., 299. Asthma. By
A. K. CRAWFORD, M.D., 306.
e. DISEASES OF THE PLEURA.
BY A. K. CRAWFORD, M.D.
Pleurodynia, 316; pleurisy, 317; hydrothorax, 325; pneumothorax,
326; hæmothorax, 327; tuberculosis of the pleura, 328; carci-
noma of the pleura, 329.
DISEASES OF THE ORGANS OF CIRCULATION.
(. THE HEART.
Introductory. By PEMBERTON DUDLEY, M.D., 330 (structure, etc., of the
heart, 331; functions of the heart, 336; diseases of nutrition of
the heart, 340; nervous relationship of the heart, 341).
b. DISEASES OF THE ENDOCARDIUM.
By E. M. HALE, M.D.
Endocarditis, 344 (simple endocarditis, 344; acute ulcerative endo-
carditis, 348). Valvular diseases of the heart, 355; general con-
siderations, 355; lesions of the aortic valves, 361 [aortic stenosis,
361; aortic regurgitation, 362]; lesions of the mitral valve, 365
[mitral stenosis, 365; mitral insufficiency, 366]; diseases of the
pulmonic and tricuspid valves, 367; treatment of valvular dis-
eases of the heart, 368); heart-clots, 382; aneurism of the heart, 385.
C. DISEASES OF THE PERICARDIUM.
By
Pericarditis. By PEMBERTON DUDLEY, M.D., 386. The treatment of
pericarditis. By E. M. HALE, M.D., 408. Hydropericardium.
By PEMBERTON DUDLEY, M.D., 412. Hæmopericardium.
PEMBERTON DUDLEY, M.D., 415. Adhesions of the heart and
pericardium. By E. M. HALE, M.D., 416. Tuberculosis of the
heart. By E. M. HALE, M.D., 420. Cancerous deposits in the
heart. By E. M. HALE, M.D., 421.
d. DISEASES OF THE HEART-MUSCLE.
Myocarditis. By E. M. HALE, M.D., 422. Atrophy of the heart. By
E. M. HALE, M.D., 425. Hypertrophy and dilatation of the heart.
By E. M. HALE, M.D., 427 (general considerations, 427; hyper-
trophy, 428; treatment of hypertrophy, 437; treatment of hyper-
trophy with dilatation, 438; dilatation, 440). Fatty overgrowth
of the heart. By H. R. ARNDT, M.D., 449. Fatty degeneration of
the heart. By H. R. ARNDT, M.D., 450. (Treatment. By E. M.
14
CONTENTS.
HALE, M.D., 458.)
HALE, M.D., 462.
463.
Adventitious products, cysts, etc. By E. M.
Rupture of the heart. By E. M. HALE, M.D.,
e. NEUROSES OF THE HEART.
BY E. M. Hale, M.D.
Angina pectoris, 464; functional disorder of the heart, 474 (palpita-
tion, irritability, intermittency, etc., 474); cardiasthenia, 479.
f. DISEASES OF THE GREAT BLOODVESSELS.
BY A. R. THOMAS, M.D.
Diseases of the aorta, 481 (aortitis, 481; atheroma, 481; aneurism, 483;
stenosis, 490; embolism, 491); diseases of the pulmonary artery,
491 (aneurism, 491; stenosis, 492; embolism and thrombosis, 491);
diseases of the coronary arteries, 493; diseases of the great veins,
494 (phlebitis, 494; degeneration, 498; phlebolites, 499; varicosis,
499; thrombosis and embolism, 500; obstruction of vessels of the
brain, 502; obstruction of the pulmonary arteries, 502; obstruc-
tion of the vessels of the extremities, 503).
DISEASES OF THE ORGANS OF DIGESTION.
a. DISEASES OF THE MOUTH.
DISEASES OF THE GUMS. BY CLARENCE M. CONANT, M.D. Gum-boils,
505; epulis, 506; fungoid tumors of the gums, 507; salivary fistula,
507; dental fistula, 508. THE MORE COMMON AFFECTIONS OF THE
TEETH. BY CLARENCE M. CONANT, M.D. Odontalgia, 508; swelled
face, 511; disorders of dentition, 512. DISEASES OF THE TONGUE.
By CLARENCE M. CONANT, M.D. Paralysis of the tongue, 518; in-
flammation of the tongue, 519; cancer of the tongue, 521; simple
ulceration of the tongue, 523. DISEASES OF THE SALIVARY GLANDS
AND THEIR DUCTS. BY CLARENCE M. CONANT, M.D. Ranula, 524.
DISEASES OF THE TONSILS. BY CLARENCE M. CONANT, M.D. Ton-
sillitis, 525; hypertrophy of the tonsils, 528. DISEASES OF THE
PHARNYX. By W. T. LAIRD, M.D. Acute catarrhal sore throat,
529; chronic catarrhal sore throat, 535; chronic follicular sore
throat, 537; ulcerated sore throat, 542; membranous sore throat,
545; gangrenous sore throat, 548; retropharyngeal abscess, 551;
diffuse inflammation of the connective tissue of the neck, 555;
DISEASES OF THE MUCOUS MEMBRANE OF THE MOUTH. BY CLAR-
ENCE M. CONANT, M.D. Thrush, 558; stomatitis, 561; gangrene
of the cheeks, 562.
b. DISEASES OF THE ŒSOPHAGUS.
BY W. T. LAIRD, M.D.
Inflammation of the esophagus, 564; stricture of the esophagus, 567;
dilatation of the esophagus, 570; perforation and rupture of the
CONTENTS.
15
œsophagus, 573; morbid growths of the oesophagus, 574; neuroses
of the oesophagus, 577 (spasmodic stricture, 577; paralysis of the
œsophagus, 582).
C. DISEASES OF THE STOMACH.
Introductory remarks. By H. R. ARNDT, M.D., 583 (food in relation
to diseases of the stomach, 584; a general consideration of the
subject of indigestion, 586; the secretions of the stomach in their
relation to the health and disease of the organ, 588; vomiting, a
symptom, its causes and treatment, 589). Atonic dyspepsia. By
H. R. ARNDT, M.D., 593. Neuroses of the stomach. By H. R.
ARNDT, M.D., 606. Acute gastric catarrh.
Acute gastric catarrh. By H. R. ARNDT,
M.D., 616. Gastritis toxica. By H. R. ARNDT, M.D., 628. Chronic
gastric catarrh. By H. R. ARNDT, M.D., 633. Penetrating ulcer
of the stomach. By J. G. GILCHRIST, M.D., 641. Cancer of the
stomach. By J. G. GILCHRIST, M.D., 657. Hæmatemesis. By
H. R. ARNDT, M.D., 665. Stricture of the cardiac orifice of the
stomach. By H. R. ARNDT, M.D., 669. Obstruction of the pylo-
ric orifice of the stomach. By H. R. ARNDT, M.D., 671. Dilata-
tion of the stomach. By H. R. ARNDT, M.D., 672. Hypertrophy
of the walls of the stomach. By H. R. ARNDT, M.D., 675. Soften-
ing of the walls of the stomach. By H. R. ARNDT, M.D., 677. Re-
marks on diseases and abnormal conditions of the stomach which
are of unfrequent occurrence. By H. R. ARNDT, M.D., 679 (con-
traction, 679; atrophy, 679; concretions and foreign bodies in the
stomach, 680; perforation, 682; abscess in the walls, 682; rup-
ture, 682; albuminoid disease, 683; tubercle, 683).
d. DISEASES OF THE INTESTINES.
Enteralgia. By A. C. COWPERTHWAITE, M.D., 683. Enteritis. By A.
C. COWPERTHWAITE, M.D., 690. Duodenitis. By A. C. COWPER-
THWAITE, M.D., 701. Constipation. By A. C. COWPERTHWAITE,
M.D., 703. Intestinal hemorrhage. By A. C. COWPERTHWAITE,
M.D., 709. Typhlitis. By A. C. CowPERTHWAITE, M.D., 712.
Colic. By A. C. COWPERTHWAITE, M.D., 717. Colitis. By A. C.
COWPERTHWAITE, M.D., 720. Dysentery. By A. C. CowPER-
THWAITE, M.D., 721. Diarrhoea. By A. C. COWPERTHWAITE, M.D.,
729. Cholera morbus. By A. C. COWPERTHWAITE, M.D., 734.
Cholera infantum. By A. C. COWPERTHWAITE, M.D., 737. Ob-
struction of the bowels. By J. G. GILCHRIST, M.D., 745. Hernial
intestinalis. By J. G. GILCHRIST, M.D., 757. Ulceration
of
the bowels. By J. G. GILCHRIST, M.D., 770. Carcinoma of the
intestines. By J. G. GILCHRIST, M.D., 777. Diseases of the rectum
and anus. By J. G. GILCHRIST, M.D., 779 (congenital imperfec-
tions, 779; hæmorrhoids, 781; prolapsus recti, 788; ulcer and
16
CONTENTS.
fissure, 790; irritable sphincter, 792; tumors of the rectum, 793;
fistula in ano, 793; stricture of the rectum, 796; cancer of the
rectum, 799; anal tumors, 801; prurigo ani, 801). Proctitis. By
A. C. COWPERTHWAITE, M.D., 803. Intestinal worms. By A. C.
COWPERTHWAITE, M.D., 806 (tænia sol., 809; ascaris lumbricoid.,
815; oxyuris verm., 818; trichocephalus dispar, 819; anchylostom.
duoden., 820; trichina spiralis, 820).
e. DISEASES OF THE PERITONEUM.
Peritonitis. By A. C. COWPERTHWAITE, M.D., 825. Tubercles of the
peritoneum. By A. C. COWPERTHWAITE, M.D., 840. Carcinoma
of the peritoneum. By J. G. GILCHRIST, M.D., 845.
By E. U. JONES, M.D., 849.
f. DISEASES OF THE LIVER.
BY W. H. DICKINSON, M.D.
Ascites.
Congestion of the liver, 859; icterus, 864; biliary calculi, 873; acute
hepatitis, 885; acute atrophy of the liver, 894; chronic atrophy
of the liver, 901; fatty liver, 911; cancer of the liver, 916; hydatid
tumors of the liver, 922; waxy liver, 929; catarrh of the bile-ducts,
933; occlusion of the portal vein, 938; purulent inflammation of
the portal vein, 941.
g. DISEASES OF THE PANCREAS.
Anatomy and physiology of the organ, 945; acute pancreatitis, 947;
chronic pancreatitis, 951; fatty degeneration, 952; amyloid pan-
creas, 952; cancer of the pancreas, 953; tubercle of the pancreas,
955; concretions in the pancreas, 955; therapeutics of diseases of
the pancreas, 956.
CONTRIBUTORS TO VOL. I.
ARNDT, H. R., M.D., of Grand Rapids, Mich.
CLAPP, HERBERT C., A.M., M.D., of Boston, Mass.
CONANT, CLARENCE M., M.D., of Orange, N. J.
COWPERTHWAITE, A. C., M.D., Ph.D., of Iowa City, Ia.
CRAWFORD, A. K., M.D., of Chicago, Ill.
DUDLEY, PEMBERTON, M.D., of Philadelphia, Pa.
GILCHRIST, J. G., M.D., of Iowa City, Ia.
HALE, E. M., M.D., of Chicago, Ill.
JONES, E. U., M.D., of Taunton, Mass.
LAIRD, W. T., M.D., of Watertown, N. Y.
MITCHELL, JOSEPH SIDNEY, A.M., M.D., of Chicago, Ill.
MORSE, LUCIUs D., M.D., of Memphis, Tenn.
THOMAS, A. R., M.D., of Philadelphia, Pa.
TRITES, W. B., M.D., of Philadelphia, Pa.
A SYSTEM OF MEDICINE.
INTRODUCTORY CHAPTER.
BY THE GENERAL EDITOR.
As health may be said to exist when the various functions of the
body are performed smoothly, harmoniously, and in order, and when
the integrity of the various structures of the body is maintained, so
disease, which is in itself merely a deviation from the standard of
health, may be said to exist when the various functions of the body
are appreciably disturbed, or when the structural integrity of any
organ is impaired. Both terms are terms of convenience, and lack
absolute correctness. Absolute health hardly exists. Disease, strictly
speaking, is the universal heirloom of the human race, and holds su-
preme sway over all; but it attracts attention only when the disturb-
ances which constitute it, or which mark its presence exist to a
degree which causes discomfort.
It is the duty of the physician to care for the sick, to relieve their
suffering, and to restore them to health; in a broader sense it is the
duty of the physician to prevent the occurrence of sickness and the
spread of disease by removing, modifying, or rendering harmless the
causes, wherever found, which are likely to impair the health of an
individual, of a community, or of a race. The various studies which
teach us the nature of those vital phenomena which we call disease, the
causes which are likely to produce them, the conditions under which
certain of these phenomena are liable to occur, their perceptible ex-
pressions, their probable effect, immediate or remote, upon the in-
dividual affected, and the various means used to modify, control, or
remove these manifestations of perverted vital force, all these, col-
lectively, constitute the science of medicine. The practical application
of the science of medicine to the relief and cure of those actually sick,
or to the prevention of disease, constitutes the practice of medicine.
The science of medicine, then, is simply the sum total of all we
know of the essentials of disease, its causes, manifestations, and the
means of prevention or cure at our disposal. It is not an absolute
science, but, dealing largely with the wonderful mysteries of "life,” of
"force," of "vital phenomena," it is constantly changing its aspect,
VOL. I.-2
18
A SYSTEM OF MEDICINE.
and remodeling its teaching, as new means of observation and study
throw a new and brighter light upon those various and intimately-
connected matters which have for ages kept busy the finest intellects
of the race. That which yesterday appeared dark and incomprehen-
sible may to-day be clear and easily understood; that which to-day
is accepted as a fixed fact, the labors of some patient workman in his
laboratory or study may on the morrow prove an utter fallacy. With
it all, incessant efforts made have perfected more and more our knowl-
edge of medical science, and, judging from its present status, much
may be hoped for the future. The science of medicine, at the present
day, represents but the most recent in a long series of evolutions from
the lower to the higher plane of intellectual activity and in the attain-
ment of scientific knowledge. Each of these successive stages is char-
acterized by its own blunders, credulities, and follies; but at all times
the status of medical science has correctly represented the status of
the contemporaneous intellectual life of the race, and each successive
forward movement has been the result of rare patience, virtue, and
unselfishness on the part of those who stood in the van of the army
of progress, fully devoted to the work of lessening suffering and pain,
and freely giving their all for humanity's sake. Medicine, as well as
the church, has had its martyrs, and in their unselfish labors, devo-
tion, and unrewarded toil, is written its history.
Disease depends upon derangement either of structure or of function.
The broad division thus made facilitates the study of disease, and to
a comparatively recent date was presumed to be strictly correct. Of
late, it is held that structural derangement is present whenever dis-
turbance of function exists, and this position seems tenable. It must
then be remembered that the term "functional" derangement practi-
cally means a condition in which disturbances of function are clearly
perceptible to our senses, while with the means now at our disposal
no characteristic structural changes in the organ or organs affected
can be found, or a condition which gives us reason to presume that
the structural derangement possibly existing is one not only of a tem-
porary nature, but sure to be corrected by the physiological process
of repair. It is a matter of fact that the class of diseases which come
under the head of functional disturbances, and of which as yet no
characteristic anatomical changes have been discovered, embrace a
very large number of diseases which not only entail much suffering
upon the patient, but are often exceedingly difficult of cure.
Pathology is a term used to express the study of disease as a dis-
tinct field of scientific investigation. Pathology is divided into general
and special pathology. The former deals with those general facts and
principles which pertain either to all the various forms of disease, or
which, at least, apply to large groups; the latter embraces facts which
refer to certain well-defined special conditions, to which, as a matter
INTRODUCTORY CHAPTER.
19
of convenience, we give a certain name and a certain well-defined
place in the catalogue of diseases. The subject of inflammation, for
instance, belongs to general pathology, because inflammatory action,
with all it means, is found under a great variety of conditions, and
accompanies a large number of well-defined diseases, each of them
differing from all others in many important respects. The same thing
can be said of the condition called "fever." Such topics, on the other
hand, which pertain to the study of one well-defined disease, or which
are characteristic of it only, and cannot be found elsewhere, naturally
come under the head of special pathology.
To facilitate the study of general pathology, it has been variously
subdivided. Many of these subdivisions belong to both general and
special pathology; for instance, diagnosis may be both general and
special.
An important subject which meets the student at the very thresh-
old of the study of general pathology, is that of the nomenclature of
disease. Diseases, so called, are not well-defined crystallized material
substances, but conditions which are never quite the same in different
subjects, and which only resemble each other in certain respects;
hence the impossibility of devising a nomenclature which shall be
simple and easily understood, and shall, at the same time, meet those
requirements which must be met to make it express the conditions
sought to be covered. The instability of pathology alone is such, that
terms which to-day might justly be considered peculiarly happy and
full of meaning would become misleading through the acceptance of
some new theory, followed, of necessity, by a complete change in the
pathology of the morbid condition named, not to mention the, often,
great difficulty of adapting language, with its many imperfections, to
the peculiar needs of the case.
The use of certain suffices and prefices in connection with the
names of the affected organs constitutes one attempt to devise an
efficient and unobjectionable nomenclature.* Thus, the suffix itis
added to the anatomical name of the affected organ indicates an in-
flammation going on in the organ named (pleuritis, cerebritis, gastritis,
etc., mean inflammation of the pleura, of the cerebrum, of the stom-
ach, etc.); the suffix rhagia denotes a hæmorrhage from a mucous
surface (metrorrhagia, hæmorrhage from the uterus); the suffix œa
means a flux upon a mucous surface (cystorrhea, a transudation upon
the mucous surface of the bladder); the suffix algia signifies a non-
inflammatory pain (neuralgia, a non-inflammatory pain affecting a
nerve; gastralgia, a non-inflammatory pain affecting the gastric nerve);
the suffix æmia indicates peculiar morbid conditions of the blood, and
* See "A Treatise on the Principles and Practice of Medicine." By Austin Flint,
M.D. Philadelphia: Henry C. Lea. 1873.
20
A SYSTEM OF MEDICINE.
uria a morbid condition of the urine (uræmia, morbid accumulation
of urea in the blood; hæmaturia, the presence of blood in the urine).
The prefix hydro indicates a dropsical affection of the part named,
and pneumo the presence of air (for instance: hydrocephalus, a cere-
bral dropsy; pneumothorax, the presence of air in the chest).
The chief subdivisions of pathology deal with the causation of dis-
eases (ætiology), the pathological changes brought about in the person
of the patient by the morbific influence at work (pathological anatomy),
the external symptoms which are exhibited by the patient when
under the operation of certain morbid actions (symptomatology or
semeiology), the particular symptoms the presence of which enables the
observant physician to recognize the nature of the morbific agent at
work and to classify the disease (diagnosis), the probable termination
and duration of a case (prognosis), and the means which are to be
employed to restore health to the sick (treatment).
Etiology is the "doctrine of the causes of disease." It is general
or specific, as it deals with the causes of general or of specific diseases.
The importance of a thorough acquaintance with ætiology cannot
well be overestimated, since it practically forms the basis of all pre-
ventive, or prophylactic, treatment. Furthermore, a knowledge of the
cause of disease is likely to be an important factor in shaping the
treatment of each individual case, since a knowledge of the cause
implies an attempt to secure its removal, a condition upon which only.
too often hangs the life of the individual patient, and of others yet to
be under the influence of the same causative force.
The causes of disease vary greatly in their nature; consequently,
the subdivisions of etiology which suggest themselves are numerous
and varied. Causes may be internal or external; overwork, worry, or
fatigue render a person liable to certain diseases, and are classed with
internal causes; malarial influence or sudden changes in atmospheric
conditions produce sickness, and are external causes. Authors men-
tion traumatic causes; ordinary or specific causes, i. e., those to which
all are exposed, and those which operate within certain limits, and
produce certain unvarying effects, as the yellow-fever poison. When
diseases occur without any appreciable or traceable cause, they are
said to occur spontaneously, an expression which is only approximately
correct. We hear also of primary and secondary causes, classing among
the latter those "complications" in which one disease partially or
wholly disappears, to be followed by another to which it stands in
relation of cause to effect.
The most natural division of ætiology, and the one most satisfactory,
is that which divides the causes of disease into: a, predisposing; b,
exciting.
Predisposing Causes.-Among the predisposing causes, constitu-
tional and individual peculiarities hold an important place. Sex de-
INTRODUCTORY CHAPTER.
21
serves consideration, because it involves the exercise of certain func-
tions and the performance of certain duties which, in various ways,
may establish fixed tendencies to certain derangements, both func-
tional and structural. Each sex possesses its own marked anatomical
and physiological peculiarities, and the organs of generation may
become the seat of morbid action. Moreover, the daily life of man
and woman differ greatly, each being productive of results more or
less exclusively its own, and having its own sources of danger to
health. Age is an important factor, and one which deserves careful
study. The different periods of life, and more especially the extremes
of life, are liable to morbid conditions which are rarely, and some-
times never, found at any other period of life. We may here mention
the derangements of the organs of digestion of young infants, with a
whole train of secondary diseases; the diseases which depend upon,
and follow in the wake of, dentition; the diseases of more advanced
childhood, as measles, scarlet fever, diphtheria, rickets, intestinal
worms; the disturbances which are likely to occur at the period of
puberty, as chorea, epilepsy, hysteria; the rheumatic, paralytic, and
other, affections which beset the downhill path of life, depending very
largely upon the gradual but sure decay of the physical and mental
vigor of the aged. Aside from this, experience has established certain
general facts in connection with this subject, which prove what may
be called a partial limitation of certain diseases to certain periods of
life. We know, for instance, that persons who have passed the twen-
tieth year of their life are comparatively free from danger of epilepsy,
that gout rarely attacks young people, and that certain derangements
of the urinary apparatus are almost limited to advanced age.
Individual Peculiarities.-Under this head we may consider
occupation and position in life, the habits established, and tempera-
ment, as predisposing causes of disease. It is generally understood
that position in life, and the occupation followed, have a bearing upon
health. The laboring man is obliged to live frugally and to work
hard in order to supply his family with the necessaries of life; he is
often exposed to inclement weather; is insufficiently clothed, poorly
fed, and many times at his task when physically unable to labor with
comfort and safety to himself. Moreover, his home surroundings are
quite apt to be at variance with sanitary laws; improper ventilation,
badly arranged rooms, exposure to draughts from doors and windows
which were carelessly built, owing to the necessity of building at the
lowest rate of expense possible, overcrowding of rooms, and many
causes due to poverty and, perhaps, to ignorance and carelessness,
combine to render this class of people fit subjects for diseases caused
by physical overwork, exposure, ill-feeding, and lack of proper sani-
tary surroundings. Fortunately, the regular hours necessitated by
habits of constant employment, the absence of excitement, of great
22
A SYSTEM OF MEDICINE.
disappointments and of crushed ambitions, compensate to a certain.
extent for the drawbacks of their position. The more favored classes,
usually possessed of a liberal income, are not obliged to expose them-
selves to inclemency of weather, have healthful surroundings, and
avoid, in the very nature of things, many of the causes of illness.
which are ever at work among the poor. They are exposed, however,
to dangers peculiar to their position. The necessity of constantly
providing large amounts of money is liable to necessitate intense
application to business, and to produce an amount of anxiety which
often results in serious bodily and mental mischief. Crushing disap-
pointments; failure in business; high political, professional, and
social aspirations; the exertion made to gratify ambition; liberal in-
dulgence in social dissipation, and the keeping of irregular hours
finally tell upon the most vigorous frame, and a broken-down nervous
system, with the infinite variety of ailments which this term covers,
belong largely to this class of persons.
•
OCCUPATION per se is to a certain extent a disease-producing factor.
The pursuit of certain trades involves peculiar dangers; painters suffer
from a characteristic affection of the wrist; compositors are prover-
bially favored subjects of tubercular phthisis; occupations which in-
volve close confinement predispose to constipation, and consequently
to hæmorrhoidal troubles. Saleswomen are rarely without a lame.
back, and, like their sisters, the sewing girls, are subject to disorders
of the pelvic organs. The Wall Street speculator is sure to suffer from
nervous disorders, and not unfrequently becomes a victim of insanity.
Habits of Life have their influence upon health. The habitual
use of alcoholic stimulants produces characteristic results; tobacco,
too freely used, leaves its impression upon the system, and the "tobacco
heart" is but one of the many disorders to which it may lead. Per-
sistent violation of dietetic rules, as eating too often, too rapidly, too
freely, predisposes and leads to derangements of digestion. Immod-
erate and unnatural gratification of the sexual instinct predisposes to
certain morbid conditions by the immoderate "wear and tear" and by
the excessive waste produced by such indulgence; disturbances of the
nervous system-often very serious-are likely to result, and spinal
irritation, paralytic affections, softening of the brain or spinal marrow,
and insanity, have been traced directly to depravity of this sort.
Temperament needs to be considered here. For obvious reasons
each temperament predisposes to a certain class of disorders.
A ner-
vous temperament means a tendency to nervous affections and mental
disorders; a sanguine temperament involves a predisposition to morbid
states characterized by inflammatory action; a lymphatic temperament,
wanting in powers of resistance, tends to strumous affections, glandu-
lar, catarrhal, and dropsical difficulties; the bilious temperament tends
to derangements of digestion, and is particularly liable, when partak-
INTRODUCTORY CHAPTER.
23
ing of the nervous temperament, to moodiness, petulancy, irritability
of temper, and to profound melancholy.
Intermarriage is classed by some authors among predisposing
causes of disease. It is generally understood that children of parents
who are near blood-relatives are almost sure to be invalids, to have a
marked predisposition to tubercular diseases, to functional disturb-
ances of the nervous system, or to be born monstrosities. It is a
fact that children of such parents are quite likely to suffer from the
afflictions pointed out. The question arises, however, how much
blood-relationship on the part of parents has to do with it. We know
that the same results may follow when parents who are not blood-rela-
tives resemble each other closely or perfectly in temperament, or when
both parents have inherited a tendency to the same morbid conditions.
If both parents are of a marked lymphatic temperament, or possess
a typical nervous temperament, no experienced medical man will ex-
pect the results of such a union to be perfect specimens of humanity;
on the contrary, he will expect to find in their children the character-
istic weak points of the lymphatic or of the nervous temperament, as
the case may be, intensified to such a degree as to lessen greatly the
usefulness, and to shorten materially the duration, of their life. Or if
the parents are consumptives, it would be a most remarkable event.
were their children to escape an early death from consumption. Most
likely, the unhappy results of intermarriage among near blood-rela-
tives are due to the incidental factor that the parents, descending from
the same stock, partake of the same temperament and of a tendency
to the same class of diseases. The temperament and the diathesis
peculiar to both, in case of the marriage of either with a person of an
opposite temperament, and one capable of counteracting existing
weak points by a needed supply of vigor, would probably be rendered
comparatively harmless, and would generally not affect in a marked
manner the offspring of such a union; in fact, nature thus endeavors
to preserve
and to increase the healthfulness and vitality of the human
But if the existing evil is not thus corrected; if, on the contrary,
inborn weaknesses are intensified by an illy-mated marriage, we must
expect to see the children pay bitterly for the lack of judgment on
the part of their parents. Intermarriage, then, we are led to main-
tain, is not of itself productive of harm if by such intermarriage no
physiological laws are violated; such laws violated, the products of
the marriage are bound to be frail and misshapen, whether the parents
are first cousins, or quite without the ties of blood-relationship. This
position is sustained by the fact that the reigning families of Europe
have practiced intermarriage for an indefinite length of time, and that
their members possess a full share of physical and mental vigor.
race.
Inherited Tendency to certain diseases is one of the most impor-
tant of predisposing causes of disease. Children, as has already been
24
A SYSTEM OF MEDICINE.
stated, reflect largely the peculiar make-up of their parents, and very
many persons have transmitted to them from their parents, and carry
in them from the hour of their birth, the seeds of a disease which, not
accident interfering or preventing, eventually becomes the cause of
their death. The term diathesis is used to denote this inherited ten-
dency to certain forms of disease; thus, we speak of a scrofulous, or
cancerous, or tubercular diathesis, meaning that the person spoken of
is, by inheritance, predisposed to scrofulosis, cancer, or tuberculosis.
The term diathesis is exchanged for cachexia when the threatening dis-
ease has actually broken out, and has left its characteristic mark upon
the countenance and physical organization of the patient; thus, a
person is said to have a cancerous cachexia when the appearance of
the countenance, and of the whole person, indicates to the observant
physician that the patient is suffering from the ravages of cancer. This
inherited tendency is by no means confined to syphilitic, scrofulous,
tubercular, or cancerous diseases; nervous affections, catarrhal diffi-
culties, rheumatic tendencies, in fact, a very large number of diseases,
may thus be handed from generation to generation.
Previously existing Diseases may become an ætiological factor,
either by leaving behind them a tendency to a repetition of the same
disease (epilepsy, acute rheumatism, angina pectoris, and others), or
by destroying more or less extensively the structural or functional in-
tegrity of an organ, thus lessening its powers of resistance to an invad-
ing morbific force. A person may have passed through an attack of
pneumonia; before fully recovering he is exposed to a severe draught,
and takes cold; the still sensitive condition of his lungs becomes a
predisposing factor of disease, and he passes through a second attack
of pneumonia, where, from the same exposure, no serious result would
have occurred had perfect recovery from the first attack taken place;
or, certain deposits, perhaps calcareous, remain imbedded in the lung
tissues, the result of a disease apparently cured; the presence of this
foreign substance under favorable conditions may give rise to phthisis.
There is also held to exist a peculiar relationship, not yet understood,
between certain diseases by which one is almost sure to predispose,
whenever it occurs, to certain other diseases; such a relationship exists.
between chorea, rheumatism, and scarlet fever.
The bearing of climate and temperature must not be overlooked. We
know that each climate has its own special scourge. The northern
climate predisposes to rheumatic and catarrhal affections; the tem-
perate zone is the home of tubercular phthisis; and malignant fevers
and dysentery in its severest form prevail in the tropics. The seasons
of the year are characterized by the prevalence of certain diseases.
Affections of the respiratory organs occur chiefly in the cold seasons ;
fevers and diseases of the digestive apparatus prevail during the heated
term.
INTRODUCTORY CHAPTER.
25
Special Causes.-The etiological factors which have been con-
sidered might appropriately be classed among the general predisposing
causes of disease; the special causes embrace a series of conditions and
phenomena of which we have as yet only a limited knowledge.
It has been observed that diseases occur which attack a large num-
ber of persons living within a certain well-defined territory, the terri-
torial lines being sharply cut, and the diseases not spreading beyond
these territorial limits. It is evident that such diseases are due to
some force outside of the human body, to which all are exposed alike,
and which does not exist beyond the limits defined. The conditions.
warrant our assuming that this disease-spreading force, called miasm,
emanates from the soil; diseases thus produced, and limited to locali-
ties, are called endemic. Other forces are not limited by sectional
boundaries, but the disease-breeding presence makes itself felt through-
out large tracts of country, often devastating a vast extent of territory,
travelling from continent to continent, spreading suffering and death
wherever it goes. It is not always possible to determine the starting-
point of this intangible, terrible something; we know that the air is
its carrier, and that its migratory powers are almost unlimited. The
class of diseases thus produced we call epidemic, and small-pox belongs
to it.
Intimately connected with the subject of epidemic disease is that of
contagion and infection. These terms are often used synonymously,
and it is at times difficult to distinguish between them. It may be
said that contagion, or contagium, involves the transmission of a dis-
ease from one animal or person to another, or from one part of the
body to another, by contact, either direct or indirect; in fact, when the
term is employed in its more correct and limited sense, it denotes the
transmission of a disease from person to person without contact, me-
diate or intermediate, the infectious matter being conveyed in the
atmosphere, and acting upon the infected person by being inhaled.
The term infection is also employed to designate the morbid and spe-
cific changes obtained by the direct introduction of certain disease-
products into a healthy body, producing in the latter characteristic
changes by a multiplication of the specific matter introduced. In
this sense the term infection is applied to the production of syphilis
or cancer, meaning the direct introduction into the system of a healthy
person of the specific poison of syphilis or cancer, or by injecting, for
instance, into the capillary circulation or into the stomach of an ani-
mal, tubercular matter for the purpose of artificially producing tuber-
culosis. The accidental introduction of pus in this manner produces
that long and serious train of secondary phenomena called pyæmia.
The study of this entire subject is yet in its early infancy, and is sur-
rounded on all sides by difficulties which seem almost insurmountable.
26
A SYSTEM OF MEDICINE.
The importance of the study in its direct bearing upon the prevention
of disease is so clear that it only needs to be pointed out.
It does not lie within the province of this work to enter upon a
thorough discussion of this perplexing, yet fascinating, subject. So
far as it has a practical bearing upon the special pathological condi-
tions which are considered in these volumes, and as it affects the
treatment of the diseases herein mentioned, it will receive due atten-
tion at the proper time and place. It suffices to state here that the
contagia are generally and naturally divided into two classes, the
parasites and the true metabolic contagia. The first class includes the
various parasites which make their way into the living human organ-
ism, there to multiply indefinitely, either actually destroying the
organism of which they have taken possession, or living a compara-
tively harmless existence, producing only such annoyances and symp-
toms as arise from their mechanical presence. The itch and trichinosis
are diseases produced by this class of contagia. The true contagia
embrace that vast variety of peculiar morbific agents whose disease-
producing power depends upon their capacity for absolutely unlimited
multiplication, and which always produces the same characteristic
result upon the body by them attacked. Schwann was the first to
introduce the term metabolic because their action depends upon the
peculiar property exerted in certain living cells of changing in a char-
acteristic, unvarying manner the character of the living substance with
which they are brought into contact.
An important factor in connection with the practical effect of con-
tagious substances upon the health of the human family is the suscep-
tibility of the individual to the action of the contagion. As all seeds.
require for their growth and reproduction certain properties in the
soil in which they are planted, and without which they cannot live,
so the different contagia, to become operative, to take ground and to
multiply, require on the part of persons exposed to their action cer-
tain, as yet unknown, peculiarities of constitution, and without the
existence of these peculiarities the contagia remain inoperative. It is
known that some persons are repeatedly exposed to small-pox, but do
not take the disease; others require but the slightest exposure to fall
ready victims to the contagium which produces the disease, and, in ex-
ceptional cases, the soil, i. e., the particular organism, is so favorable to
the reception of the contagium that the disease may be reproduced a
second or a third time. We cannot tell wherein lies this peculiar sus-
ceptibility to these extraneous forces or substances; it is, however, safe
to presume that large powers of resistance, in other words, an abun-
dance of vitality, backed by habits of cleanliness and prudence, are
of paramount importance in modifying and in successfully resisting
the action of these potent agents.
The term zymotic diseases is often used in connection with that class
INTRODUCTORY ('HAPTER.
27
of disorders which has just been discussed. The term was introduced
by Dr. William Farr, and implies the production of disease by a pro-
cess analogous to fermentation; the agents capable of producing this
process he calls zymotic principles, and he uses the terms syphiline, vario-
line, etc., to denote substances which have it in their power to produce
syphilis, variola, and so forth. The term was originally used with
considerable freedom and latitude, but is now almost wholly restricted
to miasmatic diseases.
Exciting Causes.-In considering the exciting causes of disease
we deal with a subject far more easily grasped than the one just dis-
cussed; they are merely, to use the language of Dr. Flint, Sen., "that
which acts the part of the match when everything is ready for an ex-
plosion." They may be of the nature of a mechanical obstruction in
some duct, tube, or vessel, regardless of the origin of first cause; they
may be surgical, often the result of violence. Cases of poisoning be-
long here, including not only malicious poisoning, but those due to
accidental exposure, to the action of deleterious substances incidental
to the pursuit of trades, not to forget the too free use of calomel, qui-
nine, narcotics, and other active drugs, in the hands of reckless physi-
cians. Exposure to cold, and, in fact, a large variety of agencies
which, under other circumstances, deserve mention as predisposing
causes, may, at certain times and under differing conditions, become
important exciting causes.
Pathological Anatomy.-This subdivision of pathology deals
with the morbid changes in the various structures, solids and fluids,
of the body. Many of these changes may be recognized by the naked
eye; a vast majority of them, however, are visible only under the
microscope, and it is to the wonderful usefulness of this instrument
that we owe nearly all that which makes pathological anatomy of prac-
tical value to the profession. The chief value of this branch of medical
science lies in the fact that it furnishes certain positive and reliable data
which explain much of the working of the sick-making agents with
which the physician deals. In examining the changes wrought upon
the tissues of the body, we practically read the traces left behind by
the morbific agent which has been busy at its work of destruction,
and we are thus enabled, in many cases, to understand the manner in
which it accomplishes its mission. By putting together our knowl-
edge of the functions of the body in a state of health, the manifold
symptoms exhibited by the patient while ill, and the appearance of
the structures after death has taken place, we can make a fairly cor-
rect estimate of the importance and the meaning of symptoms which
would otherwise not be understood.
The thoughtful student of medicine will not overestimate the reli-
ance to be placed upon pathological anatomy. We must not forget
that the condition laid bare by the scalpel is almost always the final
28
A SYSTEM OF MEDICINE.
result of the morbid process which existed before death, showing, at
best, only the very last form or stage of destruction accomplished by
the disease, and leaving us to draw our own conclusions concerning
that long and important chain of events which led from a state of
health to final dissolution. Furthermore, it is impossible to determine
whether the changes observed at a post-mortem examination occurred
before or after death, and this single consideration is quite enough to
reflect seriously upon the judgment of those who expect the most
wonderful and positive results from the testimony of organic matter
which undergoes such rapid and inexplainable changes from the
instant the life-giving principle departs from it.
Semeiology or Symptomatology.-Symptoms constitute the
external or appreciable manifestations of the presence of a disease;
semeiology is that branch of pathology which deals with symptoms.
Diseases cannot exist without producing symptoms, for each func-
tional disturbance, and each structural change going on within the
living body, is bound to produce effects of which the senses take
prompt cognizance. The enumeration of all the symptoms observed
during the existence of a certain disease in an individual, duly ar-
ranged in the order of their occurrence, and faithfully described, con-
stitutes the natural history of the case.
When we wish to give the natural or clinical history of a disease as
a type of morbid action, we carefully analyze the largest number of
cases within our observation, record the symptoms observed in all,
analyze their reliability and the frequency of their occurrence, expunge
those which were found in exceptional cases only, and retain those.
which were observed to be generally or invariably present; we also
note the progressive stages of development which occurred, and the
course the disease ran. In treating of contagious diseases we note
the time which elapsed from the time of reception of the contagion to
the time when the first positive manifestations of its presence were
observed; this period is named the stage of incubation. Nearly all
diseases manifest their approach by certain signs, which experience
has taught us to rightly interpret; the period during which these early
symptoms occur is called the prodromic stage of a disease. It is also
customary to include in this description, or natural history, of a disease
those secondary affections which are likely to follow in their wake,
and to which they hold the relation of predisposing and, at times, ex-*
citing causes; these are called the sequela of the disease. In connec-
tion, we also note the probable termination of the disease under
certain described conditions. Symptoms are subjective or objective.
Subjective symptoms are those which are experienced by the patient
alone, and which can be had from no other source. Objective symp-
toms are the result of the physician's observation, and are wholly
independent of anything the patient says or feels. As a matter of
INTRODUCTORY CHAPTER.
29
course, the subjective symptoms reflect, to a large extent, the indi-
viduality of the patient, and must be carefully scrutinized before their
acceptance as reliable. Children and idiotic persons can furnish no
subjective symptoms, and in the treatment of their diseases the phy-
sician is thrown wholly upon his own resources. Imaginative and
nervous persons are likely to exaggerate suffering; that which to
people more self-contained is merely pain, is by them described as
"terrible," "agonizing," and so forth. Lack of intelligence, or of ex-
perience, or of language, leads to the faulty use of terms, and may
carry an impression not at all designed by the patient. Special
reasons may induce patients to deny the existence of peculiar symp-
toms; thus, married men may deny the existence of a gonorrhoeal
discharge, or, women, more particularly the unmarried, may suppress
successfully outer manifestations of labor pains. On the other hand,
persons may pretend to suffer from epilepsy, paralysis, or insanity, to
escape rendering laborious service or punishment for crimes committed.
It requires at such times no small amount of shrewdness, and an ex-
cellent knowledge of human nature, keen penetration, and an intimate
acquaintance with medical science, especially with the symptoms
which express the presence of morbid conditions, to correctly weigh
the reliability and importance of subjective symptoms. Again, there
exists danger of dismissing too summarily, and of treating as wholly
unreliable, symptoms furnished us by patients. Many physicians of
large experience have learned the necessity of carefully noting as im-
portant many subjective symptoms which to the mass of medical
practitioners would seem far too trivial to deserve attention. Those phy-
sicians especially who have learned to prescribe in accordance with the
homoeopathic law, fully appreciate the correctness of this statement,
and can bear ample testimony to the fact that in many cases subjec-
tive symptoms which, on their face, seemed utterly unworthy of even
slight consideration-particularly those of the mind, and that class
which are placed under "modalities,"-often furnish the key to the
diagnosis and cure of obscure and unpromising cases.
Of the presence of objective symptoms the patient is frequently un-
conscious, and their recognition depends upon the keenness of obser-
vation and upon the thoroughness of the training of the physician.
Distinguishing between the two classes of symptoms, basing the dis-
tinction upon their relative value, we frequently apply to the objective
symptoms the term "sign," speaking of physical "signs," the result of
physical examination of certain organs. In contradistinction, the
term "symptom," or "vital symptom " is limited entirely to subjective
symptoms.
Other classifications of symptoms are made. Accidental symptoms
are those which occur by "accident," having no bearing upon, or di-
rect connection with, the morbid condition which is presented, and
30
A SYSTEM OF MEDICINE.
which we seek to cure. Diagnostic symptoms are those the occurrence
of which is limited to a comparatively small number of diseases; their
presence aids greatly in determining the character of a given disease,
i. e., in making a diagnosis, and naturally they increase in value as
their occurrence is limited to a small number of diseases. A very few
symptoms occur only in one disease to the exclusion of all other mor-
bid conditions, and their presence virtually determines the diagnosis.
Such symptoms are called pathognomonic. A peculiar rust-colored
expectoration is found in but one disease, pneumonia; hence, this
symptom is pathognomonic of pneumonia; the crepitant râle, heard
chiefly in pneumonia, if not absolutely pathognomonic, is a strongly
diagnostic symptom.
The clinical importance of certain objective symptoms cannot be
overestimated, and extended observation, based upon the use of ap-
propriate instruments, has resulted in an accumulation of established
facts which require more extended notice.
Clinical Thermometry.-The temperature of the body indicates
the degree of fever present. An approximate knowledge of the tem-
perature may be had by contact of the hand of the observer with the
body of the patient; a positive knowledge can only be had by the use.
of the clinical thermometer. The temperature of the body in health,
taken in the axilla or mouth, registers 37.0° C., or 98.0° F.; in the
vagina or rectum it registers from one-fourth to one-half of one degree
higher. Sex and occupation have no marked influence upon it; age,
to a certain extent, affects it. Very young infants, during the first
week, or so, of their life, have a temperature somewhat high, and aged
people show a slight decrease. Both extremes of life are marked by
susceptibility of their bodily temperature to outside influences. In
persons in a normal state of health, each day is marked by a gradual
rise and fall of the temperature; it is lowest between the hours of 2 A.M.
and 6 A.M., and highest between 5 P.M. and 8 P.M. In the middle of
the day there occurs frequently an interruption of the otherwise fairly
continuous rise of temperature. This daily fluctuation of the heat of
the body, usually not exceeding 2,3° F., is an item of importance,
since it is well marked even in a state of sickness. Bodily exercise
and eating cause a rise of temperature; tea increases heat; alcohol
diminishes it.
10
The clinical thermometer is so generally known that a description
of the instrument is not needed. The self-registering thermometer
should always be used; its reliability should be tested by repeated
comparison with a standard instrument, or by a series of tests made
with it upon persons in a state of health. The scale in common use
in this country and in England is that of Fahrenheit; in Germany
and France that of Celsius is used by preference. The temperature.
of the body is obtained by placing the instrument within the closed
INTRODUCTORY CHAPTER.
$1
C
axilla, mouth, vagina, or rectum, and allowing it to remain until the
mercury refuses to rise higher, or to sink lower; the time necessary to
secure a correct register varies from twelve to fifteen minutes. The
axilla is used by preference, and the following mode of using it is to
be observed: "The bulb of the thermometer should be introduced
beneath the border of the pectoralis major, the arm brought close to
the side of the body, and the forearm across the breast; the patient
then, with his other hand, either keeps the instrument in position, or
supports the arm which is pressed against the chest. In the cases of
children and weakly persons the attendants must look to the fixation
of the instrument. The thermometer must remain in position 15 to
20 minutes before the mercury can be said to have reached its utmost
height, as it is only when the arm is brought into contact with the
side of the thorax that the axilla becomes a closed cavity; its tem-
perature, therefore, rises slowly to that of the interior of the body.
It thus serves no purpose to warm the instrument before using it;
time may be economized, however, by causing the patient to close the
axilla shortly before putting in the thermometer, 4 or 5 minutes
being then sufficient for making an observation, which is nearly as
rapidly as it can be done in the rectum or vagina. This shorter method
may be conveniently employed when observations have to be fre-
quently repeated, as, for instance, every three or four hours."—(Dr. Paul
Guttmann, in Handbook of Physical Diagnosis.)
Thermometrical observations should be made twice each day, in the
morning and in the evening, as near as possible the hours when the
extremes of the daily fluctuation are reached. Under circumstances
of peculiar danger it may become necessary to repeat the observations
more frequently.
Since this subject will receive constant attention in connection with
special pathology, the enumeration in this place of a few general facts
belonging to clinical thermometry will answer our present purpose.
It is well to remember that a sudden rise or a sudden fall in tempera-
ture of the body during the progress of an illness should always
excite our suspicions. A sudden rise, even if other symptoms are flat-
tering, indicates danger of a relapse, or the occurrence of some unex-
pected complication; the same may be said when the high tempera-
ture continues in spite of an abatement of the severity of other symp-
toms. A progressive rise of temperature is decidedly unfavorable.
A sudden fall usually means collapse, as from severe hæmorrhage in
typhoid fever. On the other hand, a fall of the temperature while a
disease is at its height, is a good symptom, and promises convalescence
if it remains stationary at the point reached.
The following table, from Baeumler,* gives the clinical bearing of
temperature:
* Quain's Medical Dictionary; article, "Temperature."
32
A SYSTEM OF MEDICINE.
1. Temperature below the normal:
a. Temperature of collapse, below 97° F.
b. Sub-normal temperature, 97°-98° F.
2. Normal temperature, 98°-99.5° F.
3. Temperature above the normal :
a. Sub-febrile temperature, 99.5°-100.5° F.
b. Febrile temperature of moderate degree, 100.5°-102° F.,
morning; 102.2°-103° F., evening.
c. Febrile temperature of high degree, 102.5° F. and more in
the morning; 105°-106° F. in the evening.
d. Hyperpyrexia, 105.8°-107.5° F. and more; extremely dan-
gerous.
In a general way, a temperature approaching 104°-105° F. is found
in serious illness; rising above 105° F. it means great danger to life,
and touching 108° F. it means death. An exception to this rule is
to be noted in favor of intermittent fever; during the progress of this
disease the temperature often remains for several hours at a remarka-
bly high point.
Depression of temperature is found during collapse in typhoid fever,
acute peritonitis, cases of poisoning, and in profuse hæmorrhage. Wast-
ing diseases, loss of vital fluids, and starvation lower the bodily tempera-
ture; the same applies to diseases of the brain and spinal cord, and to
severe diseases of the upper spine; in the third stage of cholera the
temperature often sinks as low as 94° F. Baeumler reports a case of
carbolic-acid poisoning, which came under his observation, in which
the temperature fell to 93.92° F. Chronic diseases, characterized by a
waste of tissue and by dropsical effusions, are generally accompanied
by depression of temperature.
Elevation of temperature accompanies the diseases ushered in by a
rigor, that is, those of an inflammatory nature and of infectious origin;
rigors, also, which are of an evanescent character are usually thus
characterized; certain injuries to the brain and spinal cord are marked
by a high temperature. Wunderlich records a case of tetanus in
which he noted 112.55° F.
In continued fevers the temperature at first rises quickly, and, after
reaching its maximum height, remains stationary for an indefinite
period, returning gradually to the normal. If the temperature rises
again during seeming convalescence, a relapse may be expected. The
fluctuations are not marked with accustomed clearness. In many in-
flammatory diseases the temperature remains at its maximum height
for several days, and then returns rapidly to the normal, or, for a brief
period of time, to a point slightly below the normal, thus giving rise
to a crisis. In another class of fevers, the maximum height of tem-
perature is reached slowly, but, once reached, is stubbornly main-
tained for a great period of time, the daily fluctuations of temperature
INTRODUCTORY CHAPTER.
33
becoming well-defined exacerbations and remissions. Recovery takes.
place with a very gradual return to the normal temperature, the even-
ing exacerbations becoming gradually lighter or disappearing entirely,
or both morning and evening temperature showing a gradual decline.
The term lysis denotes this gradual return to the normal temperature
in these remittent fevers.
The intermittent fevers are characterized by intense action through-
out, the paroxysm coming on with peculiar violence, and the tempera-
ture running up to a point which, under other conditions, would be
considered very dangerous; the return to the normal is as prompt.
These attacks are repeated every second, third, or fourth day, the pa-
tient being free from rise of temperature during the intervals between
the paroxysms.
The pre-mortal stage of inflammatory diseases is usually character-
ized by a steady increase of heat, the rise often continuing for some
time after death; in other cases the temperature sinks as life ebbs away.
The Pulse. From time immemorial medical men have under-
stood the great value of the pulse as a reliable indicator of disturbance
in almost any part of the body. Although often unable to account
for the existence, under similar conditions, of certain peculiarities of
the pulse-beat, ample observation established, during the very dawn of
medical science, rules which are accepted as reliable and important
clinical facts even at this day.
The pulse consists of the distension of the arterial system caused by
the influx of blood into the aorta from the left ventricle of the heart;
it is felt usually at the wrist, by making upon the artery gentle pres-
sure with the finger; at times the pulse is more clearly perceptible in
other localities, as at the temple, or at the femoral artery. The normal
pulse in the adult man ranges from 70 to 80 beats in the minute, is
even in force, and regular in rhythm. It is more frequent in women
than in men, and in young children and aged people than in persons
in the prime of life; in new-born infants it beats from 125 to 140 beats
per minute, and gradually lessens in frequency as maturity is ap-
proached. It is at its lowest average when lying down, increases upon
assuming the sitting posture, and still more upon rising. Its frequency
is also increased by bodily exertion and mental excitement.
As a pathological symptom, an increased pulse-rate is commonly
indicative of fever; an elevated temperature and a pulse-rate above
the normal are present in all fevers. A pulse-rate of 100 per minute
betrays slight fever; from 100 to 115 shows moderate fever; a pulse
above 115 denotes active fever. There are exceptions to this rule;
in
many affections of the heart we find a low temperature and a high
rate of pulse; again, the moribund state is often characterized by a
high temperature of the body and a low rate of the pulse. Generally
VOL. 1.-3
34
A SYSTEM OF MEDICINE.
speaking, the pulse is increased in frequency whenever there exists a
rise in the temperature of the body; the study of special pathology
will show the conditions under which such frequency exists indepen-
dent of the bodily temperature. A lessening in the frequency of the
pulse-beat is found in certain affections of the heart, notably in fatty
degeneration, in various nervous affections, in relapsing fever, and,
usually, in derangements which depend upon a vitiated state of the
blood.
The force of the pulse depends upon the muscular force of the heart;
it can be estimated by the force, on part of the finger pressed upon the
artery, which is necessary to overcome it, and indicates chiefly the
integrity of the heart-structure. The rhythm of the pulse also depends.
directly upon the rhythm of the heart's action. The variations from
a normal standard are classed under the intermittent or under the ir-
regular pulse, and may be said to arise from a derangement of innerva-
tion of the heart. A pulse is termed "intermittent" when a beat is
omitted, either at regular intervals, as at every seventh or tenth beat,
or without any regularity. Such a pulse, alone, is not positive evidence
of disease; it occurs, however, in various cardiac affections, especially
in the neuroses of the heart, in affections of the nervous system, and,
proverbially, in gout. Nervous excitement, overwork, etc., also pro-
duce it, and tobacco-smokers are particularly subject to it. A mark-
edly irregular pulse, both as to force and frequency, is found in diseases
of the heart and in affections of the respiratory organs. The pulse
may be even partially suppressed, in which case we must infer great
cardiac weakness; mechanical obstruction in the shape of aneurism
or thrombosis produce localized, or partial, suppression.
The invention of the sphygmograph has advanced our knowledge of
the peculiarities of the pulse, because it increases our means for care-
fully observing it; this instrument is applied to the wrist, and leaves
upon a slip of paper tracings which represent certain pulse-character-
istics that are lost to the sense of touch. The delicacy of the instru-
ment, however, stands in the way of its general adoption by the pro-
fession, and the scope of this chapter does not warrant a discussion of
its merit and clinical value.
The ophthalmoscope, laryngoscope, and other instruments which, by
the use of refracted light, expose to view different parts of the body
not open to unaided vision, are most valuable aids not only in the
hands of the specialist, for whose use most of them were primarily
designed, but also in the daily work of the intelligent general practi-
tioner. Repeated allusion will be made to them in the chapters on
special pathology.
Diagnosis. That part of medical science which enables us to
recognize the existence of a certain disease, and to distinguish it from
INTRODUCTORY CHAPTER.
35
all other diseases, is called diagnosis. Medical diagnosis is not a science;
it is, to all intents and purposes, an art.*
The ability to correctly diagnosticate a given case is an accomplish-
ment without the possession of which no medical man is qualified to
practice the healing art. What are the chances for the recovery of a
patient whose physician is not able to recognize the nature of the mor-
bific force at work, the manner in which it accomplishes its mission of
destruction, the probable termination of the disease, and the exigencies
likely to arise during its progress?
In order to arrive at a correct diagnosis, we must, first of all, possess
an accurate knowledge of the organs of the body in health, and of their
physiological functions. Possessed of this knowledge, we can by com-
parison determine what organs are not in a state of health, and what
functions are not performed physiologically.
It then becomes necessary to study the previous history of the case,
in fact, everything which may have any bearing whatsoever on the
case. A thorough inquiry into the early history of the patient, in-
cluding his early habits, his early home-surroundings, the health of
his parents, their age, if alive, and the cause of their death, if deceased,
the diseases through which he has passed, and the degree of recovery
from them, are to be looked after, and, in chronic cases, become of great
importance, for they are likely to furnish us facts which hold a causa-
tive relation to existing disturbances. The present condition of the
patient next demands our attention, and we seek to determine the
exciting cause of the present illness. In this part of the examination
we consider the surroundings of the patient, and their bearing upon
his present condition. We ascertain possible exposure to inclemency
of weather, or to contagion, or to other inimical influences. We then
elicit the subjective symptoms of the case, carefully observing the pre-
cautions already pointed out; and at last, by the use of our senses
and of such instrumental aid as is available, secure all the objective
symptoms within reach. This done, we have gained the material with
which to work. If among the symptoms obtained we have found a
pathognomonic symptom, our task is easy; but such cases are rare.
No pathognomonic or diagnostic symptom being present, we recall
those diseases which are suggested by the symptoms obtained, and
reduce their number by excluding from the list those whose causes
and symptoms do not accord with the probable causes and with the
presenting symptoms of the case before us. This process of "exclud-
ing" or of eliminating is by all means the most satisfactory, and usually
leads to a solution of the problem before us. If it becomes difficult
* "That part of medicine whose object is the discrimination of diseases, and the
knowledge of the pathognomonic signs of each" (Robley Dunglison).—“The art
of recognizing the presence of a disease, and of distinguishing different diseases from
each other. The term is also applied to the result obtained" (R. Quain).
36
A SYSTEM OF MEDICINE.
to distinguish between two diseases, each of them presenting a certain
number of symptoms found in the case before us, we must arrive at a
final conclusion by carefully weighing the importance of the symptoms.
present or absent, and by a thorough study of all the pathological
questions involved, not to forget a close search for symptoms of possi-
ble diagnostic value.
The above rules are those usually observed in making a diagnosis.
Practical experience is an indispensable factor; patience, tact, thorough-
ness and keen powers of observation, however, are all important, to say
nothing of that intuition by which the born diagnostician arrives quickly,
and without apparent effort, at the solution of a problem which, to
others, presents almost insurmountable difficulties.
Prognosis. When the physician, carefully weighing the evidence
in a case, forms an opinion concerning the probable course and termi-
nation of a disease, of its immediate effects, and of its more remote
bearing upon the life or health of the patient, he prognosticates, and the
opinion thus formed and delivered constitutes his prognosis of the case.
A prognosis may be general or special; for instance, we know that the
average case of intermittent fever is quite likely to recover, and that,
on the other hand, a patient sick of malignant scarlet fever is more
likely not to get well; hence, we say our prognosis in intermittent
fever is favorable, while that in malignant scarlet fever is unfavorable;
this is general prognosis. Applying the same principle to an indi-
vidual case, we deal with special prognosis.
The correctness of a prognosis depends largely upon the possession
of the same qualities which make the good diagnostician, namely, a
thorough knowledge of the science of medicine, powers of close observa-
tion, and soundness of judgment. The experienced practitioner is fully
aware of the mistake he is liable to make, and his candor will be
tempered with caution.
To forecast the probable termination of a disease, it is, first of all,
necessary to have a correct understanding of its nature and of its usual
mode of termination; the latter may be complete recovery, partial
recovery, or death. This general "drift" of the case depends largely
upon the organs and structures which are involved in the morbid ac-
tion.
The violence of the attack must next be taken into consideration,
and the existence of certain important symptoms present in the
individual case before us must receive our attention; for instance, a
patient may be sick with a type of fever which we know tends to full
recovery; in the particular case before us, however, the clinical ther-
mometer may indicate the necessity of making a very guarded, and
possibly unfavorable prognosis. The patient himself next claims our
attention. We inquire into his age, and estimate carefully his powers
of resistance and endurance; his surroundings are considered as well,
INTRODUCTORY CHAPTER.
37
as the care he is likely to receive, and the means at our disposal to meet
those indications which will probably arise from time to time. In fact,
in making a prognosis, we cannot be too painstaking in considering the
bearing of many seemingly insignificant conditions which are readily
overlooked, while they frequently decide between life and death.
Treatment.—The treatment of disease embraces the various agen-
cies employed to remove, modify, and render harmless the causes of
disease, and to restore health to the afflicted. The science and art of
medicine finds its highest expression and chief aim in the prevention
and cure of disease.
All physicians agree to the correctness of the proposition that "it is
the first and sole duty of the physician to restore health to the sick."*
Physicians differ, however, in their estimate of the efficacy of the
various means at their disposal for bringing about this desirable ob-
ject; this difference of opinion is shown particularly in that portion
of this chapter which is devoted to therapeutics. Medical men who
possess similarity of opinion on this point, collectively form what are
called "schools" of medicine. Much of the advance made in medical
science is due to the honorable rivalry existing between the schools in
their praiseworthy attempts to discover new agents with which to re-
lieve suffering.
It will answer the purpose of this chapter to consider the subject of
"treatment” under two heads, the preventive treatment, and the di-
rect treatment of disease.
The preventive, or prophylactic, treatment of disease is based upon our
knowledge of the causes of disease, and consists of the removal of such
causes as soon as found. It is seen at a glance that the subject is vast
in extent, and of supreme importance in its bearing upon the general
public health, as well as upon the health of the individual.
Of late years, the importance of a thorough knowledge of the æti-
ology of disease has become more and more fully understood, and the
continued agitation of problems intimately connected with causation
of disease, and of the public health, has resulted in organized and
systematic efforts on a large scale, in many instances at the public ex-
pense and under governmental supervision, to study the causes of
diseases, more particularly the nature of epidemics. The fruits of
these researches have been made of the greatest possible practical
value by disseminating among the masses a correct knowledge of the
causes of the contagious, and other diseases, and the means by which
their occurrence may be avoided, or their spread be prevented. Legis-
lation has also been had, forcing the people to observe those laws of
health and those precautions which are best calculated to improve
the general health, and to lessen the danger of and from the occurrence
of sweeping epidemics.
* Organon of Medicine, by Samuel Hahnemann, 1.
38
A SYSTEM OF MEDICINE.
The principal subjects with which preventive treatment deals are:
the nature of contagion, and the means to prevent the occurrence and
spread of diseases which are the result of its action upon the human
body; personal hygiene in its relation to health and disease; clima-
tology, and its bearing upon health and disease; and sanitary science
proper, including a very large variety of special topics, such as sewage,
ventilation, quarantine, and others.
The physician, upon recognizing the existence of what is, or what
promises to become, a disease-making factor, promptly removes it, or,
if this is impossible, lessens to the extent of his power the dangers
arising from it. In case of a threatening epidemic, he has recourse to
the best means at his disposal to narrow its field of operation. If a
patient lives in a climate not suitable to him, and which thus is a
standing menace to his health, he advises a change of climate; if a
nervous patient is driven almost to madness by the existence of some
annoyance which may be removed, the physician promptly insures its
removal; if the drinking water of a family under his care is unfit for
such purpose, he points out the danger, and insists upon having it
removed; if a person inclined to tubercular disease is engaged in an
occupation which in itself predisposes to the formation of tubercles, the
physician sees that a change of occupation is had. These examples
merely illustrate what constitutes preventive treatment, and their list
might be carried much further.
Under direct treatment of disease we class everything the physician
does to ameliorate the severity of a disease, and to cure it at the earliest
moment possible. Direct treatment includes therapeutics and what,
for the sake of convenience, may be termed auxiliary treatment; the
latter embraces regimen, dietetics, the use of baths, and the thousand
and one things which the careful physician and nurse find simply in-
valuable in the treatment of the sick.
Therapeutics.-The individuality of homoeopathic practice rests.
upon the proposition that disease, so-called, is simply the appreciable
effect of the action of an inimical or morbific force upon the vital
principle, and that the disturbance thus caused must be corrected by
the administration of a remedy which, by its action upon the vital
force, yet unexplained, has the power to produce upon the healthy
human organism a series of effects closely resembling the symptoms.
which in the sick constitute the disease. The homœopathic physician,
then, in his search for the curative remedy in a given case, seeks, first
of all, for the drug which has produced upon the healthy a series of
symptoms which bear the closest possible similarity to the symptoms.
of the disease which he is called upon to remove. This remedy found,
he administers of it just enough, and not more than enough, to remove
the pathological or morbid symptoms which he desires to cure.
Hahnemann devotes to this subject considerable space, and most
INTRODUCTORY CHAPTER.
39
painstakingly instructs his followers in the method he believes best.
adapted to the successful accomplishment of the object in view. The
chief points to be observed are these: The physician first obtains all
the information which the patient himself can furnish; he must use
care and judgment in deciding what points are worthy of credence,
and what symptoms, if any, are to be rejected; the value of symptoms
thus obtained depends less upon the intelligence than upon the honesty
of the patient. After eliciting from the patient these subjective symp-
toms, the physician, by a system of cross-examining the patient, sup-
plements and corrects the information secured, taking care, however,
not to throw aside lightly, on account of their seeming unimportance,
any statements made by the patient in reference to purely subjective
symptoms. This accomplished, the physician completes the "totality"
of symptoms by a searching examination of every detail which has
the slightest bearing upon the case, including the previous history of the
patient, the probable causes of the disease, and all those points already
discussed as possible ætiological factors. It must be borne in mind
that the practitioner who is most skilful in thus examining a patient,
and who fully understands the use of the clinical thermometer, of the
stethoscope, and of other means of physical diagnosis, accumulates a
wealth of facts which not only prove the means of making a correct
diagnosis and prognosis, but which form equally reliable guides in the
treatment of disease; for the "totality of symptoms," correctly speak-
ing, means nothing short of the sum total of all discernible deviations
from the standard of health.
The art of "taking a case" can be fully acquired only by practice,
and to a large extent is a matter of tact, even of intuition. Thor-
oughness, however, is within the reach of all. The young practitioner
will do well to go from organ to organ in regular order, to ascertain.
thus methodically existing organic lesions and functional derange-
ments. His knowledge of the history and semeiology of disease must
then be called into service to connect symptoms already discovered
with morbid conditions with which such symptoms are known fre-
quently to be associated; it needs only reference to the peculiar head-
aches in women which point almost unerringly to the existence of
certain uterine difficulties, or to the connection which is known to
exist between exophthalmic goitre and certain affections of the heart,
to illustrate the importance of this latter point.
The selection of the homoeopathic remedy follows next, and is the
result of an intelligent comparison of the symptoms of the artificial
or drug-disease with the symptoms found in the patient. The hom-
œopathic relation between the two series of symptoms depends upon
a correspondence, not only of superficial appearances, but extends to
the structures affected, and even to a correspondence between the
various stages of development of the drug-disease on one hand, and
40
A SYSTEM OF MEDICINE.
of the existing pathological condition on the other. A number of
remedies, acting in different ways and upon different structures, not
infrequently present alike a certain important symptom; it is evident
that the choice between them must depend upon a deeper-lying cor-
respondence than can be ascertained from mere mechanical "symp-
tom-covering," and that this choice cannot be made intelligently un-
less the prescriber takes into consideration the manner in which the
drug-symptom is produced upon the healthy, and seeks to establish
a similarity between this process and that which has given rise to the
production of the same symptom in the sick.
The correct remedy found, it is to be given in a dose, or in doses,
sufficiently powerful to fulfil its legitimate object of curing the patient.
At the present stage of our therapeutic science, it is difficult to lay
down fixed rules concerning the exact amount of medicine required
to produce stated results. We can tell how large an amount of ipe-
cacuanha will produce emesis, or how many grains of opium will pro-
duce fatal consequences; it is quite another thing to state how small
a dose of ipecacuanha will cure Master B., aged six years, of a violent
cough; or to explain why Miss D., also aged six, and closely resem-
bling Master B., derives no benefit whatever from a dose of ipecacu-
anha which promptly cures Master B., while a dose of the same rem-
edy much heavier, or infinitely smaller, as the case may be, promptly
relieves her difficulties. It is, however, safe always to remember that
a very small dose of the right remedy is sure to be followed by relief
in all curable cases, and that the young physician will best serve his
own interests, and those of his patients, by studiously avoiding
practicing upon preconceived notions, so far as this concerns the ex-
clusive use of any one set of attenuations of drugs. The vast amount
of reliable clinical experience now at our disposal proves, most con-
clusively, the wonderful efficacy of minute doses of the properly
selected remedy, and the drift of the entire medical world is now in
the direction of the small doses, first indicated by Hahnemann. Doses
are now given by physicians of the physiological schools of practice
which, a very few years ago, would have subjected them to gross ridi-
cule and to relentless persecution. It is not possible to determine, at
this writing, where the limit of drug-attenuation really lies; and, while
the administration of too large a dose of medicine is a thing to be
avoided painstakingly, it is no less shortsighted to employ in the treat-
ment of the sick a dose likely to be too small to accomplish its mis-
sion of mercy.
In view of this atmosphere of uncertainty which
hangs about the question of dose, no reference will be made to it in
this work, save in a few isolated instances, in which it represents the
personal experience of the respective contributors.
The repetition of dose, and the length of the intervals to be observed
between the periodical administration of the prescribed remedy, has
INTRODUCTORY CHAPTER.
41
also given rise to much useless controversy. Hahnemann teaches that
the physician is to give but one dose of the indicated remedy, and
must wait until improvement has ceased before considering whether
to give a second dose of the same remedy or to select a new remedy.
Many homoeopathic physicians, especially the older members of the
school, still follow this teaching, allowing hours, days, and, in chronic
cases, many weeks to elapse before repeating the dose, or before
changing the remedy. In the treatment of acute cases an overwhelm-
ing majority of homoeopathic physicians now prefer to repeat the rem-
edy at comparatively short intervals, lengthening these intervals as
danger to the patient grows less. In the treatment of chronic diseases
the medicine employed should always be given at intervals of consid-
erable length.
The sum total, then, of homoeopathic practice depends upon: a,
the selection of the indicated remedy; b, the administration of this
remedy in the smallest dose which, in the judgment of the prescriber,
promises to cure the patient, and at such intervals as seem advisable
to the attending physician.
Auxiliary Treatment.-One of the greatest of the many services.
done suffering humanity by Hahnemann, is his teaching concerning
the use of powerful narcotics for the relief of pain, a symptom almost
always present in disease. The use of narcotics and hypnotics for
the relief of pain is of ancient origin, and constitutes an interesting.
chapter in the history of medicine. To the ancient physicians much
of the knowledge of disease, now alike the property of the learned and
of the masses, was practically unknown, and curative treatment in
most instances was wholly out of the question. The relation, in most
cases, between cause and effect, or between the disturbing force at
work and the outer expression of the disturbance created, were con-
siderations which received very little attention. It seemed natural to
think that the suppression of pain constitutes the real treatment of
disease. A person suffering intensely, put under the quieting influ-
ence of a powerful narcotic mixture, was presumed to have received.
the benefit of all medical skill can do. The same procedure was re-
sorted to again and again, until the patient made either an accidental
recovery, or died. Centuries of observation and study necessarily
modified somewhat this pernicious practice, but up to the time of
Hahnemann no energetic and systematic warfare had been waged
against a practice then so universally employed in the treatment of
the sick. Hahnemann insisted upon pointing out, on every possible
occasion, the harm likely to result from the indiscriminate use of the
narcotics, more especially of the preparations of opium. He empha-
sized the following facts: by the use of narcotics the physician delib-
erately suppresses the manifestation of important subjective symp-
toms; during the period of suspended consciousness the ravages of
42
A SYSTEM OF MEDICINE.
the morbific force, not only go on without interruption, but their de-
velopment cannot be watched by the attending physician, and no
measures can be taken to meet them with that promptness upon which
the very life of the patient may depend; their use is very likely to
lead to loss of valuable time, and, since they do not affect curatively
the existing disease, recovery is retarded, and death may result when
it could have been avoided by proper curative measures; the use of
narcotics is followed by the appearance of symptoms which are wholly
due to their use and are characteristic of them. These drug-symp-
toms modify and blend with the symptoms caused by the disease, and
thus greatly increase the difficulty of finding a curative remedy; the
physician, finding it easier to prescribe a narcotic than to search for
the right remedy, is led to cultivate habits of idleness and of careless-
ness, to the great detriment of his patient; the continued use of nar-
cotics leads often to the formation of habits in the patient which are
really more disastrous in their consequences than was the original
disease.
These propositions practically embody the views of Hahnemann
upon this important subject, and are upheld to-day by homoeopathic
physicians everywhere.
Leaders in all important movements necessarily occupy extreme
positions, and Hahnemann was soon led to practically deny the ne-
cessity of ever having recourse to the use of narcotics for the relief of
pain or for sleep-giving purposes. Homoeopathic physicians, as a class,
do not fully indorse this extreme position, but recognize the fact that
purely palliative measures are at times indispensable. Whenever a
patient suffers an unbearable amount of distress, the possible necessity
of using narcotics for purely palliative purposes invariably arises. In
cases which are not curable, the omission of such relief as can be
given without endangering life, may become little less than a criminal.
neglect of duty. Recent investigations have fully demonstrated the
fact that severe and long-continued pain acts as a potent factor in
producing seated diseases, and must often be stopped at all hazards.
The homœopathic physician, then, is presumed to fully realize the
responsibility he assumes when suspending curative treatment for the
employment of mere temporary make-shifts; he is presumed to be
patient and skilful in the use of the means which will permanently
remove the cause of pain; he is to be influenced not by the clamor of
the patient, who refuses to bear pain, but by his own knowledge of the
nature of diseases, and by a clear understanding of the reliability of
the means at his disposal to combat the morbific force at work. On
the other hand, he must ever remember that he is a physician in the
broadest sense of the word, and that his knowledge of the noble pro-
fession he has chosen must be sufficiently broad to indicate when and
where the question of affording immediate, though temporary, relief
INTRODUCTORY CHAPTER.
43
of pain becomes one of paramount importance; and at such times no
fear of unfriendly criticism dare stand in the way of a fearless and
faithful discharge of his duty as a physician. The exercise of this
duty requires much circumspection and soundness of judgment.
Abundant testimony exists, drawn from the experience of our most
successful practitioners, that the true homœopathic remedy relieves
even intense pain with astonishing promptness, and that the use of
opiates, and of other narcotics, rarely becomes a necessity in the prac-
tice of the intelligent and consistent homœopath.
Auxiliary treatment embraces not only the use of narcotics for the
purpose of furnishing temporary relief from pain, and of giving sleep,
but covers that infinite variety of measures which aid in securing the
comfort of the patient, thus contributing to his favorable progress
toward recovery. Mention may be made here of the important part
played by the skilful nurse, and of all those various resources which
are classed under regimen. The use of hot and cold water, of crude
remedies employed for specific and usually temporary purposes (as
the use of amyl nitrite in emergencies likely to arise in certain dis-
eases of the heart), of stimulants, of electricity, and of many agents of
minor importance,-all these must be familiar topics to the physician
who desires to take to his couch, after the day's labor is completed,
the consciousness that he has done his full duty by those who have
intrusted to him their own life or the life of those dear to them.
PHYSICAL DIAGNOSIS.
BY HERBERT C. CLAPP, A.M., M.D., BOSTON, MASS.
PHYSICAL diagnosis is the discrimination of diseases by means of the
principles of physical science. In health there are certain physical.
conditions incident to the internal organs of the body, many of which
can be recognized by our senses by the observation of certain phenom-
ena which are called physical signs. Many changes which disease pro-
duces in these physical conditions can be recognized also by means of
physical signs. The interpretation of the meaning of these signs is
not to be arrived at by any theoretical a priori conceptions, but only
by clinical observation confirmed by post-mortem examination.
There are six methods of physical exploration: Inspection, Mensura-
ion, Palpation, Succussion, Percussion and Auscultation. The first and
second depend on the sense of sight, the third on that of touch, and
the fourth, fifth and sixth on that of hearing. The phenomena which
these methods give us are called physical signs, in distinction from
what are commonly called the symptoms of disease-the rational or
vital symptoms, such as headache, sleeplessness, pains of various kinds,
etc. The former are objective, the latter subjective. The former can
be relied on to give accurate information, not only in the examination
of intelligent and honest patients, but also in cases of idiocy, insanity,
coma; in cases where the patient speaks a foreign language which
can not be understood, or for other reasons has difficulty in expressing
himself, or tries to deceive the physician; and also in dealing with
young children; in all of which latter cases the subjective phenomena
are not to be depended on. Where both are obtainable, physical
signs and rational symptoms should always go together in forming a
diagnosis. Neither should be relied on to the exclusion of the other,
but they should be mutually supplementary. Likewise, the signs
resulting from the different methods of physical exploration should
always be compared, in order to ascertain to what extent they are con-
firmatory of each other. The conclusions derived from one method
might mislead, but if all conspire to tell the same story, it can not be
false.
It is unnecessary at the present day to uphold, by means of argument,
the value of physical diagnosis. He who is thoroughly posted in it
has an immense advantage over him who knows nothing about it.
To become thoroughly posted, however, is the work of time. It re-
quires not only a theoretical knowledge of facts which should be so
familiar that they are constantly "at the fingers' ends," so to speak,
PHYSICAL DIAGNOSIS.
45
but also a practical knowledge of these facts which can only be ob-
tained by the actual examination of patients; and after this knowledge.
has been obtained, it can only be preserved by a very frequent appli-
cation of it. Therefore, the physician should constantly resort to
these methods of examination in as many cases as possible, to prevent
growing rusty.
Regions of the Chest and Abdomen.-In order to describe
clearly to others the location of physical signs, and also to aid one's
own memory, it is convenient to divide the surface of the chest and
abdomen into regions. Although such divisions are, to a great extent,
arbitrary, yet the following are now almost universally accepted by
physicians in all parts of the world.
Anteriorly, the divisions of the chest on each side are the supra-
clavicular, the clavicular, the infra-clavicular, the mammary, and the
infra-mammary regions. Between these are the supra-sternal and the
upper and lower sternal regions. Laterally, come the axillary and the
infra-axillary regions. Posteriorly, are the scapular, the infra-scapular
and the inter-scapular regions. To designate the side, the term right
or left must be prefixed.
The supra-clavicular region extends from half an inch to an inch and
a half above the clavicle, and contains the apex of the lung. The cla-
vicular region corresponds to the clavicle, and contains the apex of the
lung. The infra-clavicular region extends from the clavicle to the third
rib, and contains the upper part of the lung. The mammary region
extends from the third to the sixth rib, and its contents on the right
and left side differ materially. The right is mostly occupied by the
right lung, the slanting lower border of which nearly corresponds to
the lower boundary of this region, and covers the upper part of the
liver, which pushes up behind it; it contains also parts of the right
auricle and ventricle. The upper intercostal fissure begins at the
fourth cartilage, and the lower not far beneath it. The left mammary
region, besides containing the lung (the left intercostal fissure being
near the fifth rib), contains the most important part of the præcordia.
The infra-mammary region extends from the sixth rib to a curved line
corresponding to the edges of the false ribs. On the right it contains
the liver, with the lower part of the lung during a full inspiration; and
on the left the lower part of the lung, with parts of the stomach,
spleen and left lobe of the liver. The supra-sternal region is the space
above the sternal notch, and contains chiefly the trachea. The upper
sternal region extends to the third rib, and contains the bifurcation of
the trachea at the second rib. Below this point the lungs come almost
in contact. It also contains the ascending and transverse portions.
of the aorta, and a part of the pulmonary artery. The lower sternal
region covers the sternum below the third rib, and contains the greater
part of the right, and a portion of the left ventricle. The axillary
46
A SYSTEM OF MEDICINE.
region lies above a horizontal prolongation of the lower boundary of
the mammary region to the inferior angle of the scapula, and con-
tains a portion of the upper lobe or lobes of the lung with main
FIG. 1.

10
3
4
3
6
6
7
8:
bronchi. The infra-axillary region extends below this to the edges of
the false ribs, and contains the lower edge of the lung, and also the
liver on the right side, and the stomach and spleen on the left. The
PHYSICAL DIAGNOSIS.
47
scapular region covers that bone, and contains parts of the upper and
lower lobes of the lungs. The interlobar fissure ends at the upper
part of the lower scapular space. The infra-scapular region extends to
the twelfth rib from a horizontal line connecting the lower angle of the
FIG. 2.

2
31
8
911
10
11
4
9
10
12
scapula with the eighth dorsal vertebra, and contains the lungs to
the eleventh ribs, and the upper parts of the kidneys (more of the left);
and also on the right a part of the liver, and on the left a part of the
intestines and spleen. The inter-scapular region extends from the
inner margin of the scapula to the spinal column, and contains lung
48
A SYSTEM OF MEDICINE.
substance and the main bronchi, the bifurcation of the trachea being
opposite the third dorsal vertebra, below which is the descending
aorta.
The abdomen is divided into regions which have also been pretty
universally adopted. The upper regions, it will be seen, encroach
more or less upon the lower divisions of the chest just given. It will
be simplest to look at them as three general zones, each of which is
again subdivided into three regions.
The upper zone extends from the curved line of the diaphragm above
to a horizontal plane passing through the cartilages of the ninth rib;
the middle zone from this plane to another passing through the
anterior superior spinous processes of the ilia; and the lower zone
beneath this. By drawing two parallel lines from the centre of Pou-
part's ligament to the cartilages of the eighth rib, each of these three
zones is subdivided into three regions, a middle and two lateral.
The epigastric region is the middle region of the upper zone, and
contains the middle and pyloric end of the stomach, the pancreas and
parts of the liver and aorta. The right hypochondriac region is at the
right end of the upper zone, and contains the right lobe of the liver,
the gall-bladder, the hepatic flexure of the colon, and parts of the duo-
denum and of the right kidney. The left hypochondriac region is at the
left end of the upper zone, and contains the large end of the stomach,
the narrow extremity of the pancreas, the splenic flexure of the colon,
the spleen and the upper half of the left kidney. The umbilical region
is the central region of the middle zone, and contains the transverse
colon, the lower part of the duodenum, part of the omentum and mes-
entery, a portion of the jejunum and ileum, and the abdominal aorta.
The right lumbar region is at the right end of the middle zone, and
contains the ascending colon, the lower part of the right kidney, and
part of the duodenum and jejunum. The left lumbar region is at the
left end of the middle zone, and contains the descending colon, the
lower part of the left kidney, and part of the jejunum. The hypogastric
or pubic region is the central region of the lower zone, and contains the
ileum, the bladder (if distended), and the gravid uterus. The right
iliac or inguinal region is at the right end of the lower zone, and con-
tains the cæcum, the appendix cæci, and the lower end of the ileum.
The left iliac or inguinal region is at the left end of the lower zone, and
contains the sigmoid flexure of the colon.
PHYSICAL EXAMINATION OF THE LUNGS.
Each one of the six different methods of physical exploration is
available for an examination of the lungs; but by far the most im-
The principal
portant of them are Auscultation and Percussion.
PHYSICAL DIAGNOSIS.
49
information to be derived from each of these methods will be pre-
sented under its appropriate heading. In the narrow limits allotted
to this chapter much condensation will be necessary, and only those
points will be brought forward which are of the greatest practical in-
terest.
Inspection.-Examination by the eye is generally the first method
of physical exploration to be resorted to. By it we are able to de-
termine facts of importance with regard to the form and size of the
chest, and also with regard to the respiratory movements. The chest
should either be divested entirely of clothing, or different parts may
be uncovered in succession, if modesty demands it.
The patient
should, if possible, sit or stand erect in a good light. Strictly speak-
ing, owing to slight spinal curvature, or other causes, the great ma-
jority of perfectly healthy chests are not absolutely symmetrical; still,
for all practical purposes we may so regard them, and may generally
attribute any marked deviation, on one side or the other, to intra-
thoracic disease.
The chest is enlarged in emphysema, pleuritic effusions, pneumo-
hydrothorax, and pneumonia. In emphysema the enlargement occurs.
in the upper and middle portions, on one or both sides (if the latter,
more on one than on the other). In pneumonia the side of the chest
is enlarged only very slightly, and often not at all. The greatest
change in this direction accompanies the accumulation of a large
quantity of liquid, or air, or both, in the pleural cavity. In pleurisy
the enlargement is most marked at the lower part of the chest, and
the intercostal depressions are often effaced, sometimes, even, to bulg-
ing.
The chest is seen to be contracted, often to a very great extent, after
recovery from chronic pleurisy, where the lung has been compressed
for weeks and months, and also bound down by adhesions; both of
which are great obstacles to its proper re-expansion. It may be
slightly contracted after pneumonia. Partial contraction, in the neigh-
borhood of the clavicle, is very often observed in phthisis, especially
when far advanced.
The respiratory movement of the chest is almost abolished, on one
side, over a large accumulation of fluid in the pleural cavity, but cor-
respondingly increased on the other side. The same difference exists
in spinal hemiplegia. In phthisis, we often notice a difference in the
movement at the summit of the chest on the two sides. Some disease
of the lungs is generally indicated when the respirations occur oftener
than in the ratio of one to four beats of the heart.
Mensuration.-When it is desired to secure greater accuracy in
defining the size and form of the chest, and its movements in respira-
tion, the method of inspection is supplemented by that of mensura-
tion, and for this purpose a great variety of instruments, more or less
VOL. I.-4
50
A SYSTEM OF MEDICINE.
ingenious, has been devised. The practiced eye, however, can obtain
by inspection, in the great majority of cases, all the information which
is necessary in this direction, and the only disease in which mensura-
tion becomes of real value is that of pleurisy with effusion (serous or
purulent). Here, the circular measurement of the chest at the level.
of the sixth costo-sternal articulation is to be taken, and, for this pur-
pose, nothing is better than two simple tape-measures sewed together
at the starting-point of graduation. This point is to be placed over
the centre of the vertebral column, or over the mesial line in front,
and the difference in size of the two sides at the end of an expiration,
or the difference in the amount of their expansion, can be read off at
a glance. It must be remembered that, in health, in both sexes, the
right half of the chest in right-handed persons measures about half
an inch more than the left, and a similar excess on the left side is to
be noticed in left-handed individuals. In this way can the increase
or diminution in the amount of fluid in the pleural cavity be accu-
rately determined, from time to time. Spirometers have been invented
to measure the "vital capacity " of the chest, or the amount of air
which can be expelled by a single long expiration; but the physician
who trusts to them will be sure to find that they far oftener deceive
than aid him. Negatively, if a person can expel his full number of
cubic inches of air, the presumption is that his lungs are healthy;
but his failure to do so ought not to be taken as evidence of lung-
disease, as it may depend upon general muscular weakness, or lack
of practice in blowing, or upon other causes.
Palpation.—The most important information to be obtained by
palpation, or the laying on of the hand, is the determination of the
increase, diminution, or suppression of the vocal fremitus. If the
palm of the hand is placed firmly on the chest of a healthy person
while speaking, a distinct vibration or thrill will be felt, varying in
intensity with the strength and lowness of pitch of the voice, and the
amount of fat or muscle in the chest-walls. This thrill is the normal
vocal fremitus, and is of much more service as a physical sign in men
than in women or children. It is more marked on the right than on
the left side. In disease, the vocal fremitus is increased in those af
fections where the lung-tissue is more or less solidified (the latter be-
coming thus a better sound-conductor), as in pneumonia, phthisis,
compressed lung, etc., unless the larger inclosed bronchial tubes are
obstructed. It is diminished or suppressed whenever the lung is sep-
arated from the chest-walls by accumulations of liquid, or gas, or solid
lymph, in the pleural cavity, or by thickened pleuræ, and also by
solid growths, such as cancer, whether in the lung or external to it.
Succussion. This method, which is as old as Hippocrates, is only
of service in the diagnosis of one disease-pneumo-hydrothorax. It
is a splashing sound, caused by suddenly shaking the patient; is au-
PHYSICAL DIAGNOSIS.
51
tance.
dible to the applied ear, and sometimes may be heard at quite a dis-
It requires for its production a cavity filled with both fluid
and air, or gas. The sound can be imitated by shaking a bottle par-
tially filled with water. It may sometimes be heard, under favorable
conditions, in large cavities in the lungs. Being a very rough method
of handling the patient, however, and its results being easily ascer-
tainable in other ways, it is now almost never resorted to.
Percussion. As the carpenter, by pounding on the plastered wall,
tells where the beams are by the difference in sound, so can we, by
percussing or striking on the chest, locate the intra-thoracic organs in
health, and detect certain alterations in their structure when diseased.
We never strike directly, but use certain media to receive the blow, as
the finger of the left hand, or pleximeters made of gutta-percha, ivory,
rubber, glass, or wood. Most physicians use the finger, with the pal-
mar surface towards the chest; if, however, a pleximeter is desired,
the best is one recently introduced, and not usually described in the
books—a truncated cone, two inches long, with one small and one
large end-piece. The smaller end fits very nicely into the intercostal
depressions and the supra-clavicular hollow. The whole is held very
easily, like a cigar, and is, in every way, very much more convenient
than the old-fashioned flat pleximeters. With this a percussion ham-
mer should be used; Wintrich's is the best. It should be rather heavy.
If the left finger is used as a pleximeter, the tips of one or two fingers
of the right hand should be used as a hammer. The percussing fingers
should strike perpendicularly, and the whole movement should be
from the wrist. More force should be used for deep-seated parts than
for such as are superficial. The patient should stand or sit, if possi-
ble, and his body in any position should rest on the same plane.
When examined in front, if sitting, his arms should hang down;
when the side is examined, his arms should be crossed over his head;
when it is the back, they should be crossed in front, and the body
should be bent forwards. Care should be taken to compare exactly
corresponding portions on the two sides, and percussion should be
performed in the same stages of the respiratory act. The pressure of
the left finger and the force of the blow should always be alike on the
two sides.
Percussion of the Healthy Chest.-The sound varies consider-
ably according to the part of the chest percussed. The typical pulmo-
nary or normal vesicular resonance is found in the infra-clavicular region,
and is produced by the vibration of the air in the subjacent lung tissue.
It is almost as distinctly heard in the mammary and axillary regions,
but in the scapular and inter-scapular regions it is greatly muffled by
the layers of muscles and bone. Even in the same individual each
region of the chest which bounds the lungs gives forth a different
tone on percussion, and much more so in different individuals; so
52
A SYSTEM OF MEDICINE.
that there is no uniform standard of pulmonary resonance, and we are
not obliged to carry about with us a tuning-fork or other instrument
of precision, with which to keep in mind the proper tone. It is only
necessary in each case to compare carefully the resonance obtained
at one point with that of the exactly corresponding point on the other
side. It is a full, clear sound of low pitch, but no description of it
is adequate. It must be heard on the healthy body to be appreciated.
In some persons it is slightly less clear at the right than at the left
apex. Flatness on percussion, on the contrary, is the complete ab-
sence of resonance, and may be obtained with typical distinctness
over the centre of the liver. Here the sound is completely deadened.
Dulness, or diminished resonance, is intermediate between the two
preceding, the resonance being partially lost, and the pitch correspond-
ingly raised. Naturally, of this there are all gradations. It is heard.
in health over the heart and spleen, over the mammary gland in
women, and where the lungs overlap the liver and heart. Too much
cannot be said by way of urging the student to spend a great deal of
time in percussing all parts of the healthy chest, and thus gaining a
practical acquaintance with them, before proceeding to the investigation
of disease.
Percussion in Disease.-If, as a result of disease, the density
of the lung texture is altered, the resonance will likewise be changed,
and the percussion sound will pass through every gradation from
marked resonance to flatness. These modifications are usually
called dulness, flatness, tympanitic, vesiculo-tympanitic or exagger-
ated, amphoric, and cracked-metal resonance. The special char-
acteristics of dulness and its extreme, flatness, have already been ex-
plained. In disease they are caused by serum or pus in the pleural
sac, serum in the air-vesicles, partial or complete solidification of lung
tissue, tumors, etc. Where heard they indicate, therefore, either pleu-
ritic effusion, empyema, hydrothorax, pneumonia, phthisis, pulmonary
œdema, compression or collapse of lung, cancer or aneurism. The
type of tympanitic resonance can be heard by percussing the bowels
and stomach. As its name implies, it is a drum-like sound, and has
a much higher pitch than the vesicular resonance. It indicates a col-
lection of air in the pleural sac, as in pneumothorax, or a large cavity
in the lung, as in the last stage of phthisis. Contrary to what might
be expected, it is sometimes heard over partially solidified lung. The
character of the exaggerated or vesiculo-tympanitic resonance is expressed
by its name. It is a combination, in varying proportions, of the vesicu-
lar and tympanitic resonance; the more of the latter quality existing,
the higher being the pitch. The intensity is greater than normal. It
is heard in emphysema on account of the distension of the air-cells, and
also in the probably somewhat similar condition which temporarily ex-
ists in the upper part of the chest when there is a very moderate pleu-
PHYSICAL DIAGNOSIS.
53
ritic effusion or a hepatized lung in the lower part. Amphoric resonance
usually indicates phthisical cavities, and sometimes pneumothorax. It
resembles the sound produced by percussing an empty jar or by strik-
ing the cheek when the mouth is closed and fully, but not too tensely,
inflated. It is heard over large superficial cavities with thin, tense
walls, and with free communication with the bronchial tubes. Cracked-
metal, or cracked-pot resonance is a short, hollow, metallic sound, ac-
companied with hissing. If the palms of the hands are put loosely
together, and the contained air is suddenly expelled by striking the
knee, not only a good imitation will be made, but also a fair illus-
tration of its mode of production. It indicates mostly phthisical
cavities.
Auscultation.-The art of auscultation has now been brought so
near to perfection, that the physician of to-day who is thoroughly ac-
complished in it has, in the diagnosis of thoracic affections, a wonderful
advantage over the most skilled diagnostician of the beginning of this
century. An acquaintance with its theory and practice, therefore,
cannot be too strongly urged. It is said to be immediate when the un-
assisted ear is applied to the chest of the patient, and mediate when an
instrument, called a stethoscope, is used. Both methods are important,
and both should be learned. He who seldom or never applies his ear
directly to the chest becomes almost as helpless at the bedside, if he
happen to have left his stethoscope at home, as the myope without his
glasses; and, on the other hand, he who has not made himself really
familiar with the use of a good stethoscope is often heard to declare
that it is good for nothing, and that he can get along better without it.
So can a man who has not learned to ride a bicycle get along better
without such a vehicle; and yet bicycle-travelling is much more satis-
factory than walking to one who knows how to ride. With Cam-
mann's binaural stethoscope, which is by far the best instrument to
have (the old-fashioned wooden or ivory single tubes being now in
most places almost entirely antiquated), we have the great advantage
of employing our double sense of hearing, which is by no means merely
theoretical. With this instrument, also, we can keep a safe distance from
uncleanly patients, and in other cases delicacy sometimes requires it.
The stethoscope can easily be adjusted to points difficult to reach with
the ear, and it circumscribes and intensifies sounds which we desire
to get unmixed. Its rim should press firmly, equally, and evenly on
the bare skin. Its ear-pieces should follow the direction of the audi-
tory canal. One hand should support the instrument at the bulb, and
the other should hold aside the clothing. A simple elastic, which can
be replaced for two cents when worn out, regulates the pressure much
better than any patent or fancy spring. The disagreeable humming or
buzzing, which confuses the beginner, soon passes off with a little prac-
tice. If the unassisted ear is used, it is better to have some thin cov-
51
A SYSTEM OF MEDICINE.
ering for the chest, like a soft towel or an undergarment, but certainly
nothing that will rustle and add sounds of its own. The position of
the patient should be the same as for percussion, and he should gen-
erally breathe harder than usual, preserving, however, the natural
rhythm. Corresponding parts of the two sides of the chest should be
constantly compared with each other.
Respiration in Health.-If the ear or stethoscope be applied to
a healthy chest, with each inspiration will be heard a soft murmur,
which is perfectly described by the word breezy, and is of low pitch.
Its intensity varies in different persons, and in the same individual in
different parts of the chest, and it even varies, also, at different times
in the same part of the chest of the same person, according to the
force and rapidity of the respiration. The accompanying expiration
is not breezy, but feebly blowing, and when present at all is very much
shorter, and its pitch a little lower, than the inspiration. In many
cases it is absent, and when present it follows so closely that there is
no interval. This respiration is called vesicular, and is heard to best
advantage in the left infra-clavicular region. It should be remem-
bered that in the right infra-clavicular region of some persons in
health the quality of the inspiration may be a little less breezy and its
pitch a little higher, and the expiration a little longer than in the cor-
responding region in the left side. Too much stress, however, should
not be laid on this point, as the writer has frequently found from his
experience in practical teaching, that the student is very apt to overesti-
mate the amount of this difference, and thus to pass over as unim-
portant well-marked signs of disease on the right side. The vesicular
respiration varies somewhat, also, according to age. In early child-
hood its intensity is increased, and it is then called puerile. In old
age its intensity is diminished and its expiration prolonged. The
tracheal or laryngeal respiration is that heard over the healthy tra-
chea or larynx, and is entirely different from the vesicular. The
inspiration is hollow or tubular in quality, of great intensity, and of
very high pitch; the expiration which is always present is likewise
tubular in quality, is even more intense, and still higher in pitch.
The most prominent feature of all is that the expiration is as long as,
and sometimes even longer than, the inspiration; and between the
two there is a distinct interval.
Respiration in Disease.-It is of sufficient importance to bear
repetition that the healthy signs derived from auscultation, like those
of percussion, should be thoroughly mastered before proceeding to
study those found in disease. The latter have been classified very
conveniently under three heads-Intensity, Rhythm, and Quality and
Pitch.
Altered Intensity.-Under this heading are found exaggerated,
feeble, and suppressed respiration. We have already seen that the
PHYSICAL DIAGNOSIS.
55
vesicular respiration in children is precisely like that in adults, except
that it is louder. Exaggerated respiration is identical with the healthy
respiration of childhood. In disease its peculiarity is that it does not
indicate trouble where it is heard, but where it is not. In pneumonia,
for instance, if one lobe is solidified, the rest of the lung takes an in-
creased action, to supply partially the deficiency. If one whole lung
is thrown out of use, as in the case of a large pleuritic effusion, the
other lung has to work harder, and over the latter we have exaggerated
breathing. This sign is to be heard, therefore, in pneumonia, pleurisy,
phthisis, emphysema, cancer of lung, etc. Feeble respiration, on the con-
trary, is the vesicular respiration lessened in intensity. It arises from
any cause which interferes directly or indirectly with the full inflation
of the lung. We find it, therefore, in pleurisy, paralysis, pleurodynia,
croup, asthma, phthisis, tumors, and many other diseases. Suppressed
respiration, as its name indicates, is the absence of sound, and most
commonly occurs with large pleuritic effusions or pneumothorax,
where the fluid or air in the pleura entirely prevents the expansion of .
the lung.
It also occurs where there is very great obstruction in the
larger bronchi to the entrance or exit of air.
Altered Rhythm.-In jerking respiration, the inspiration, or expi-
ration, or both, are broken up into two or more puffs, instead of being
continuous. It is caused by nervousness, or shrinking on account of
the pain of pleurisy, or of intercostal neuralgia or rheumatism, in which
cases it is diffused; or by some local obstacle to the passage of air, as
in the case of tubercle or asthma, when it is limited to a part of the
chest. Prolonged expiration is oftenest caused by the obstruction of
tubercle, and sometimes by the lessened elasticity of the walls of the
dilated air-cells in emphysema. In the former case the pitch is high,
and in the latter it is low.
Altered Quality and Pitch.-One of the most important modi-
fications of the breathing in disease is the bronchial or tubular respira-
tion, which is identical except in intensity with the healthy tracheal
or laryngeal respiration, the characteristics of which have already been
described; and it can, therefore, be leisurely studied in the supra-
sternal region of any healthy person. It always indicates more or less
complete solidification of the lung substance, either from deposits or
from compression by growths or effusions, and may, therefore, be ex-
pected in pneumonia, phthisis, pleurisy with effusion, etc. In phthisis
and pleurisy it is generally found in the upper part of the chest, and
in pneumonia in the lower part.
The broncho-vesicular respiration is a combination in varied propor-
tions of the bronchial and of the normal vesicular, one or the other
element preponderating according to the amount of solidification. In
the resolution of pneumonia we have an opportunity of studying this
in all its different grades, from that which verges on the bronchial, in-
56
A SYSTEM OF MEDICINE.
dicating complete solidification, to the vesicular, indicating healthy
lung. It was formerly called rude or harsh respiration. It indicates.
partial solidification, and is, therefore, found in the same diseases as
the preceding. Cavernous respiration is sometimes with difficulty dis-
tinguished both from bronchial and vesicular respiration; but is more
hollow and lower in pitch than the former, and more blowing than the
latter. The cavity which produces it must be more or less empty, and
must have flaccid walls, and free communication with a bronchial
tube. It is often mixed with gurgling, and is oftenest found in con-
nection with the third stage of phthisis. Amphoric respiration has a
musical intonation of low pitch and often a metallic quality, and can
be imitated by blowing across the mouth of an empty bottle. It accom-
panies either inspiration or expiration, or both. The cavity which
produces it must be large, must have rigid walls which do not collapse
with expiration, and must communicate freely with a large bronchial
tube. When met with, it almost always indicates pneumo-hydrothorax
with pulmonary fistula, but sometimes a large cavity in phthisis.
Rales. These are not modifications of the normal respiration,
having no analogue in health, and are, therefore, new or adventitious
sounds. They are heard accompanying the sounds of respiration,
or else entirely supplanting them. Râle (pronounced rahl) is a
French word meaning rattle, but as now used it includes other than
merely rattling noises. It may be formed in the trachea and larynx,
two familiar instances of which are the crowing of croup and the
death-rattle in the moribund state; but it is generally applied to some.
noise made within the chest. Rales are divided for convenience into
dry and moist, the latter conveying to the ear the sensation of the
presence of liquid of some kind. Under dry rales we may classify
the sonorous, sibilant, crepitant and crackling; and under moist, the
gurgling, coarse bubbling, fine bubbling, and subcrepitant.
Dry Rales.-Sonorous rales are low-pitched, musical sounds re-
sembling snoring, buzzing, the notes of a bass viol, etc., and are pro-
duced in the large bronchi when their calibre is irregularly narrowed,
either by spasm or by swelled mucous membrane, or by the adhesion
of mucus too thick to bubble, or by pressure of a tumor. They occur
especially with expiration, but may come with inspiration. If more
or less diffused all over the chest, they indicate bronchitis or asthma;
if confined to one spot, circumscribed bronchitis secondary to phthisis
or to pneumonia. Sibilant rales are high-pitched, whistling, squeak-
ing or hissing sounds, occurring especially with inspiration, and pro-
duced in the same manner as the sonorous rales, but in the smaller
bronchial tubes. They also indicate the same diseases, and show that
they have extended to the smaller tubes. Both sibilant and sonorous
rales are peculiarly liable to change their position. Crepitant rales are
vesicular; that is, they are produced in, and indicate an affection of
PHYSICAL DIAGNOSIS.
57
the air-vesicles. At the end of each expiration in such affections a
viscid secretion glues together the walls of the air-cells, and the air
entering with the next inspiration causes a forcible separation which
gives rise to the sound. They occur only with inspiration and near
the end of it. They are very fine, quick, crackling sounds, like those
produced by throwing fine salt on a fire or by rubbing a lock of hair
between the fingers. To many the sound seems dry, although others
classify them among the moist rales; really they are so small, that it
is not easy to decide which they are. Crepitant rales occur in ædema
and in collapse of the lungs, but they are especially characteristic of
the much more common pneumonia, of which they are almost pathog-
nomonic. If heard only at the apex of the lung, phthisis is indicated.
Crackling rales, or clicking, bear some resemblance to the crepitant
rales, but the explosions, so to speak, are very much fewer in number,
often not exceeding one, two, or three, and are of larger size. They
are heard near the apex of one lung, and indicate phthisis. Their
mechanism is doubtful.
Moist Rales.-The loudest and most easy to distinguish are the
gurgling rales, which indicate, and are produced in lung cavities par-
tially filled with liquid, through which air from communicating bron-
chial tubes bubbles. The sounds are always liquid, are often very
intense, and sometimes metallic or amphoric from reverberation in
a large, hollow space, and are proportionate to the size of the cavity;
if this is small, they may be not easily distinguished from coarse
bubbling rales. They are heard with both respiratory acts, and
although they may be produced in any lung cavity, yet in the vast
majority of cases they indicate advanced phthisis. If the cavity be-
comes empty, they are replaced by cavernous respiration; if full, they
are no longer produced. Coarse and fine bubbling rales are by many
physicians still called "mucous" rales; but as they may be, and often
are, produced by serum, blood, pus, or softened tubercular deposit, as
well as by mucus, the term bubbling is very much more appropriate.
They are liquid sounds caused by the bursting of bubbles of various
sizes by the passage of air, during either inspiration or expiration,
through liquids in the bronchial tubes. The coarse bubbling rales are
formed in the larger bronchial tubes, and the fine in the smaller bron-
chial tubes; so that by the size of the bubbles we can judge of the
size of the tubes affected. Coughing sometimes modifies or even en-
tirely removes them, in the latter case often to reappear in another
place. The sounds may be nicely imitated by moistening the insides
of rubber tubes and gently blowing through them. If these rales are
more or less diffused over the whole chest, they indicate bronchitis;
if circumscribed, they indicate bronchitis secondary to phthisis or
to pneumonia, or else softened tubercle, blood, etc., in the tubes. The
subcrepitant rales are similarly formed in the very minute ramifications
58
A SYSTEM OF MEDICINE.
of the bronchial tubes. They sound very much like crepitant rales,
and are very often confounded with them. They are, however, heard
either with inspiration or expiration, or both, and have a distinctly
moist sound. They are heard in capillary bronchitis, in pulmonary
oedema, in lobar pneumonia during resolution, in incipient phthisis,
and in pulmonary hæmorrhage.
Pleuritic Friction Sounds.-In health the pleural surfaces move
noiselessly on each other, but, when roughened by inflammation,
sounds of varying intensity are heard, which are described as graz-
ing, creaking like new leather, crumpling, rubbing, etc. They ac-
company both inspiration and expiration, or inspiration alone. They
seem to be near the ear, and are sometimes attended with a friction
fremitus. They indicate pleurisy, either primary or secondary; in
the former they are usually confined to a small space at the middle or
lower part of the chest. In pleurisy secondary to phthisis they are
generally heard at or near the summit of the chest. Metallic tinkling
is a rather rare sound, resembling that of dropping shot into a tin
basin, and is almost pathognomonic of pneumo-hydrothorax.
The Voice in Health.-If the stethoscope is placed over the
larynx or trachea of a healthy person while speaking, the words will
be heard to be imperfectly articulated and accompanied with a strong
resonance, shock and vibration. The voice seems intense, concentrated, and
near the ear. There, as in all other attempts to elicit vocal phenomena,
the listener's attention is less distracted from his work if the patient
is instructed to count one, two, three repeatedly than if he undertakes.
to carry on a conversation with him. This is called the tracheal or
laryngeal voice. If the patient whispers, the sound corresponds to the
sound of expiration in tracheal or laryngeal respiration, and the whis-
pered words are transmitted more perfectly than the loud words.
This is called the tracheal whisper. If, now, the stethoscope or the ear
is applied to the healthy chest, a confused hum is heard which is much
more distinct in men with deep voices than in women and children,
and differs greatly in intensity in different parts of the chest. Indeed,
in some persons this voice, which is called the normal thoracic vocal
resonance, is absent over the entire thorax. When heard, it is diffused
and seems farther removed from the ear, as contrasted with the tra-
cheal voice. The vibrations are weakened by passing through the
spongy tissue of the lung before reaching the ear. The voice is almost
always more resonant on the right side. If the person speaking now
lowers his voice to a whisper, each word will come in a soft blowing
sound, which varies in intensity in different persons, and is heard.
mostly over the upper part of the chest. This bears the same relation
to the tracheal whisper that the healthy chest voice bears to the tra-
cheal voice, and has been called the normal bronchial whisper.
The Voice in Disease.-With the voice, as with the respiration,
PHYSICAL DIAGNOSIS.
59
there is no one standard for all parts of the chest. Corresponding
points on the two sides must be constantly compared. Diminished
and suppressed vocal resonance are simply less in intensity than the
normal, or absent altogether, and are very valuable signs in connection
with the different effusions into the pleural cavities, which partially
or entirely deaden the vocal resonance by removing the lungs from
the chest walls. They also occur if the bronchial tubes are obstructed
by mucus or by the pressure of tumors, the circulation of air in them
being thus prevented. Increased vocal resonance is simply a gain in in-
tensity, and is generally associated with the broncho-vesicular respira-
tion, and indicates the same condition of the lung-namely, a moderate
solidification. Therefore it is heard over lung tissue compressed by a
pleuritic effusion (if the latter is not too large), over collapsed pulmo-
nary lobules, and over partially solidified lung in pneumonia; but it
is of more importance in connection with phthisis. The increased
bronchial whisper, which goes with it, denotes the same conditions.
Its intensity and length are increased over the normal, its quality is
more or less tubular, and it is higher in pitch. Probably the most.
important and best marked of all the vocal phenomena is bronchophony,
which in its main characteristics bears a strong resemblance to the
healthy tracheal voice. The intensity of the latter, however, is far
greater on account of the superficial location and great size of the
trachea. The key-notes to fix bronchophony in the memory are con-
centration and nearness to the ear. The pitch is higher than in the
normal thoracic vocal resonance, and its intensity and fremitus are
variable. It indicates more or less completely solidified lung sub-
stance, which is a much better sound-conductor than the healthy
spongy tissue. It is heard to best advantage in pneumonia, and occurs
also in phthisis, and over lung condensed by effusions into the pleural
sac or by the pressure of a tumor, etc. Whispering bronchophony, which
goes with it and indicates the same conditions, is the same as the ex-
piratory sound in bronchial respiration-intensified, long, high-pitched
and tubular. It is often more marked than bronchophony itself. In
pectoriloquy, which is rare, the articulations of words are transmitted di-
rectly through the stethoscope into the ear. It thus comes even nearer
to the tracheal voice than bronchophony, of which latter it seems.
sometimes to be only an exaggeration. It is chiefly heard in phthisis,
and sometimes indicates solidification, but oftener cavities with smooth,
sound-reflecting walls. Egophony, which is likewise rare and not of
much importance when heard, is a tremulous, bleating sound like the
cry of a goat, from which it derives its name. Lænnec considered it
a sign of a thin layer of pleuritic fluid over solidified lung. The
amphoric voice and whisper are caused by reverberations in a large
cavity with rigid walls, and are hollow, metallic sounds with a musi-
cal intonation, not distinctly articulated. The amphoric (or jar-like)
·
60
A SYSTEM OF MEDICINE.
quality especially accompanies the whisper. They may be heard
over large lung cavities, but more often denote pneumo-hydrothorax.
The cavernous whisper is blowing, hollow and of low pitch, and indi-
cates a lung cavity near the surface with flaccid walls. It is found,
of course, oftenest in advanced phthisis.
From lack of space, in the above descriptions of physical signs only
the most important outlines are given. For a fuller exposition, as
well as for a complete tabular arrangement of these signs as grouped
in their proper places under the headings of the different diseases, thus
presenting, in a form very easy for comparison and for differentiation,
the physical diagnosis of diseases of the lungs as well as of the heart,
the reader is referred to the writer's work on Auscultation and Percus-
sion.*
PHYSICAL EXAMINATION OF THE HEART AND OF
AORTIC ANEURISM.
Inspection. By this is determined the form of the cardiac space
and the location of the visible impulse of the heart. In great hyper-
trophy and dilatation of this organ, especially in children, and in peri-
cardial effusion, there may be a decided bulging in this region; and a
corresponding depression may follow pericarditis or the contraction of
neighboring lung cavities. Much more important, however, are the
phenomena relating to the impulse or apex-beat, which is seen in
health in the fifth intercostal space on a line a little inside of the
nipple, occupying an area of perhaps an inch in diameter. This area
may be increased considerably under excitement. In lean persons the
impulse is very distinct, but in some it cannot be seen at all. Its
position may be somewhat modified in health by the attitude assumed
by distension of the stomach, and by the acts of respiration. In dis-
ease it may be displaced downwards by emphysema, aneurism or
other tumors; to one side or the other by pleuritic effusion, by ma-
lignant disease or contraction of the lung; upwards by enlargement
of the left lobe of the liver, by abdominal distension or by contrac-
tion of the lung, and by pericardial effusion. If the apex-beat is
lowered and to the left, and none of these causes operate, enlargement
of the heart by hypertrophy or dilatation must exist. In such cases
the area of visible impulse is increased, sometimes extending over
several intercostal spaces.
The pressure of an aneurismal tumor will often cause a bulging or
even perforation of the ribs and sternum, which is clearly visible.
Over this is seen an impulse coincident with the ventricular systole.
* A Tabular Handbook of Auscultation and Percussion; for Students and Physi-
cians. Fifth edition. By Herbert C. Clapp, A.M., M.D. Boston: Houghton, Mifflin
& Co.
PHYSICAL DIAGNOSIS.
61
The most common location of this bulging can be inferred from the
fact that the aneurism oftenest starts from the ascending or first part
of the transverse portion of the aorta, and extends to the right.
Palpation. For obtaining information this method is far superior
to inspection, since many an impulse which cannot be seen can yet
be distinctly felt by the finger. Besides locating the apex-beat by it
in such cases, we make use of it to determine the force, frequency and
regularity of the heart's action. The cardiac impulse is diminished
in force by dilatation, by pericardial effusion, by fatty degeneration,
by an emphysematous lung, by a low state of the system, or by some
diseases of the brain; it is increased in force by hypertrophy, by
functional excitement, and by the early stages of endo- and pericar-
ditis. In hypertrophy a powerful heaving movement is felt all over
the præcordia, but in dilatation we find a weak, struggling, undulating
motion. A fatty heart has a quiet, feeble, undemonstrative action,
which often cannot be felt. A peculiar thrill can sometimes be per-
ceived where a valvular lesion or a roughened pericardium exists.
Over an aneurism of the aorta a purring thrill is often felt, and also
an impulse synchronous with the heart's systole, which may be even
stronger than the heart's beat itself.
Percussion. By this means, which requires considerable skill, we
can with more or less accuracy define the outline, and thus estimate
the size of the heart. The superficial cardiac space, where the heart is
uncovered by lung, about two inches in diameter, naturally gives a
duller sound than the deep cardiac space, where the edges of the lung
overlap, and where more forcible percussion is necessary to bring out
the heart sound. Both areas will be traversed by percussing on a
vertical line drawn from the second to the sixth rib, and on a horizon-
tal line from half an inch to the right of the sternum to the left nipple.
It should be remembered that the bony sound of the sternum will
materially alter the dull sound of the heart underneath it. The apex
can best be found by palpation or by auscultation. It is difficult to
define the lower border of the heart from the upper border of the liver
(whose dulness is more absolute, however), but fortunately this is not
very important. The mammary gland in women, if well developed,
renders percussion difficult, and in children this method of diagnosis
is often very unsatisfactory. The area of præcordial dulness may be
increased by cardiac hypertrophy, dilatation, pericardial effusion, or
by retraction of the lung; it may be diminished by a full inspiration,
by pulmonary emphysema, or by air in the pericardial sac. Dulness
is found over a thoracic aneurism extending generally upwards and to
the right. Over this too forcible percussion must not be practiced.
If very large, such a tumor may compress neighboring lung tissue and
cause still further extension of dulness.
Auscultation.-By this method, which is by far the most im-
62
A SYSTEM OF MEDICINE.
portant means of diagnosis of heart affections, we decide whether
there are present the natural heart sounds, or modifications of these
natural sounds produced by disease, or certain adventitious sounds.
Auscultation will help our diagnosis also by revealing the condition.
and position of the neighboring border of the lung. The stethoscope
is peculiarly desirable for these examinations, even more so than in
lung diseases, as it isolates so nicely the sound from each part of the
heart, and as here a change of half an inch may make a considerable
difference. When the sounds are not well heard, they are rendered
more distinct (inasmuch as they are not then obscured by the respi-
ration) if the patient is asked to stop breathing for awhile. Both
sounds of the heart are audible over the whole præcordia, and often
beyond, but not with the same distinctness. The first sound is best
heard at the apex, and the second at the base. The first, or systolic,
is complex, being caused by the simultaneous contraction of the mus-
cular fibres of the ventricles, the closure of the mitral and tricuspid
valves, the impulse of the apex against the chest-walls, and probably
also from the friction of the blood against the walls of the ventricles.
It is made up, therefore, both of a muscular and of a valvular element,
each of which should be differentiated and carefully borne in mind.
for diagnostic purposes. It is accented, long, booming, and of low
pitch at the apex, but at the base is much less prominent. The second.
sound, or diastolic, is produced by the sudden tense closure of the
aortic and pulmonary valves by the reflux of blood on them, and is
short and entirely valvular. If the first is called booming, the second.
may be called tapping. Lub-b-b dup is often quoted to express the
difference. The first sound of the heart occupies four-tenths of the
cycle, the succeeding silence one-tenth, the second sound two-tenths,
and the long pause three-tenths. The student cannot be too strongly
urged to make, in the most careful manner, repeated examinations of
as many healthy hearts as possible, in order to become practically
acquainted with many points which no books can adequately express,
with the variations of the sounds as heard at different parts of the
chest, and with all the shades of difference allowable within the limits
of health, which might be easily mistaken for signs of disease. In
fact, without an exact acquaintance with the healthy sounds, it is
impossible to make the nice distinctions which are often required in
the diagnosis of heart diseases. The muscular and the valvular
elements of the first sound have been mentioned. When the former
predominates, the sound is more dull and prolonged; when the latter
is in excess, it is shorter, more sharp and slapping. In hypertrophy,
with its thick, strong walls, we have an instance of the former; in
dilatation, with its thin, weaker walls, the muscular tissue being im-
paired, we have an instance of the latter. In hypertrophy and dila-
tation combined in about equal proportions, we are apt to have a
PHYSICAL DIAGNOSIS.
63
ringing sound. On the other hand, if the auriculo-ventricular valves
are thickened or contorted, and yet sufficient, the sound is less sharp
and slapping than usual, the valvular element being less prominent.
The muscular element is naturally diminished in fatty degeneration
of the heart, general debility, anæmia, and wasting diseases, the ven-
tricular walls being ill-nourished. The first sound of the heart is
increased by excitement, by functional disorders of the organ, by
passing through solidified lung, and in cases in which the lung is
retracted so that more of the heart comes near the chest-wall. It is
diminished when it has to pass through a pericardial effusion or a
thick pad of emphysematous lung, or considerable fat or ædema in
the walls of the chest. A tympanitic abdomen will sometimes give it
a ringing, sonorous sound. The second sound of the heart, as can
readily be imagined from its mode of production, is increased by
increase of blood-pressure in the aorta and pulmonary artery. Hyper-
trophy of the left ventricle will, therefore, tend to intensify the aortic
second sound, and hypertrophy of the right ventricle the pulmonary
second sound. The obstructed circulation through the kidneys in
chronic Bright's disease, with its consequent hypertrophy of the left
ventricle, will naturally intensify the aortic second sound; and in a
similar manner, the obstructed circulation through the lungs in mitral
disease and in pulmonary emphysema, with its consequent hyper-
trophy of the right ventricle, will naturally intensify the pulmonary
second sound. When the semilunar valves are thin, the second sound
is shorter and more ringing; when they are thickened, it is duller.
Anatomically, the valves of the heart are very near together, occupy-
ing an area of only about an inch in diameter; fortunately, however,
the places of election for hearing their sounds to the best advantage
are farther apart. The aortic second sound, which is naturally stronger
than the pulmonary, is best heard in the second right intercostal space
at the edge of the sternum. The pulmonary second sound is best
heard in the second left intercostal space at the edge of the sternum.
The mitral sound is heard just above the apex-beat, and the tricuspid
just above the ensiform cartilage. The rhythm of the heart sounds
may vary considerably. The beats may be exceedingly rapid, may
be irregular in time and force, or intermittent. While these changes
very often accompany organic disease of the heart, they do not neces-
sarily indicate it, being frequently found in connection with functional
disturbances. The curious reduplication, also, of the first or second
sound, or of both, which is probably owing to want of synchronous
action of the two sides of the heart, may occur temporarily in appa-
rent health, but is oftener noticed where there is increased resistance
either in the pulmonary or systemic circulation.
Murmurs or Adventitious Heart Sounds.-These are not
modifications of the natural heart sounds, but are entirely foreign.
64
A SYSTEM OF MEDICINE.
They may be divided into two general classes-pericardial, usually
called friction sounds, and endocardial murmurs.
Pericardial friction sounds are caused by the rubbing together
of the opposing surfaces of the pericardial serous membrane rough-
ened by inflammation and its consequent fibrinous exudation. In
health this perfectly smooth, well-lubricated membrane, like the
pleura, prevents all noise, but in the first and third stages of pericarditis
(and sometimes too in the second) we hear a grazing, crumpling,
creaking or rasping sound, either feeble or loud, single or double,
occurring with or following the heart sounds. It is best heard at the
fourth rib at the left edge of the sternum, and is increased by bending
forward, by firm pressure with the stethoscope, and by a full inspira-
tion. It is superficial and usually restricted to the præcordia. At
the beginning of pericarditis it lasts from a few hours to a few days;
in the stage of effusion, it is generally lost (except sometimes at the
base of the heart), owing to the separation of the roughened surfaces.
by the fluid; and during absorption it reappears and lasts a week or
more. Occasionally a pleuritic friction sound is mistaken for it,
which can be differentiated by asking the patient to stop breathing.
Endocardial murmurs are always blowing sounds, although
they may differ greatly in character. They may be of low pitch, of
high pitch, soft, harsh, or musical; but however interesting these
variations may be, they have not as yet been proved to have any
diagnostic significance. They are produced at the orifices or within
the cavities of the heart, and represent morbid conditions either of
the blood or, far more often, of the heart itself. This latter fact deter-
mines a very important subdivision into inorganic or anæmic murmurs,
and organic (which are generally valvular) murmurs, which should
be carefully differentiated.
Anæmic or hæmic heart murmurs are always coincident with
the ventricular contractions (that is, they are systolic), and are almost
always, if not always, formed at the base of the heart. They are soft
and feeble, resembling the word who whispered, and are caused by
changes in the quality of the blood, which is more watery than usual,
and thus not adapted to the usual surfaces and passages. They are
not constant, like organic murmurs, neither do they produce cardiac
enlargement, and the aortic second sound is neither increased nor
diminished. The general signs of anæmia are present, and in the
jugular veins is produced a continuous hum, called bruit de diable,
which is suspended by pressure with the finger. The dynamic mur-
mur, of rare occurrence, is a temporary blowing sound, occasionally
heard in a violently excited heart with no organic disease.
Organic heart murmurs are far more common, and are pro-
duced by some organic change at or near one of the orifices. This
may be a contraction, usually called stenosis, or an excrescence or
PHYSICAL DIAGNOSIS.
65
vegetation, or calcareous deposit, which interposes more or less of a
local obstruction to the flow of blood in its proper direction; or it
may be a puckering or other injury of the valves, resulting from dis-
ease, rendering them incompetent to close completely the openings,
and thus allowing regurgitation of blood through them. The intensity
of the murmur is not a measure of the amount of damage done.
Small vegetations on the valves, or irregular attachments of the ten-
dinous cords thrown across the blood current, or mere roughness (as
in some cases of endocarditis which recover without permanent in-
jury) may occasion considerable noise, and yet be comparatively harm-
less in their consequences. The real test of the seriousness of a lesion
occasioning a murmur is its effect after awhile on the heart-walls.
The murmur may be so loud as completely to drown out the sound
of the heart with which it comes, or, as is oftener the case, both may
be heard distinctly together. Change of posture may sometimes make
a murmur faint, or even disappear altogether.
After the murmur, by exclusion, has been proved to be endocardial
and organic, the next step is to ascertain what lesion it indicates.
For this purpose the seat, rhythm, and diffusion of the murmur are
necessary. First, its seat must be located. The places of election for
hearing to best advantage the sounds of the different valves of the
heart have already been stated. The same places are to be selected
for listening to the different valvular murmurs. Those indicating
trouble with the aortic valves are heard at the second right intercostal
space (or occasionally at the second or third left space) at the edge of
the sternum; the pulmonary at the second left intercostal space at
the edge of the sternum; the mitral at or near the apex; and the
tricuspid just above the ensiform cartilage.
Having thus located the valve affected, the next step is to determine.
which one of the two diseases incident to each of the four valves of
the heart the patient has; in other words, is the lesion occasioning
the murmur obstructive or regurgitant? This depends entirely on
the rhythm of the murmur, i. e., whether it is systolic, diastolic, or
presystolic. It is here taken for granted that so much of the physio-
logical action of the heart as relates to the time and direction of the
blood currents is perfectly fresh in the memory, for this is the ground-
work of all knowledge of valvular lesions. It will be recalled that
with the contraction of the left and right ventricles-the systole, the
first sound of the heart-the blood is forced through the semilunar
valves of the aorta and pulmonary artery respectively, which open to
allow its passage, and the mitral and tricuspid valves are forcibly
closed, to prevent the reflux of blood into the auricles, whence it
recently came. With the diastole, the arterial coats of the aorta and
pulmonary artery recoil on the recently introduced columns of blood
which now fill them, and consequently, the semilunar valves on each
VOL. I.-5
66
A SYSTEM OF MEDICINE.
་
side close-with a noise which we call the second sound of the heart—
and, fitting tightly, perfectly prevent the reflux of blood into the ven-
tricles. In the last part of the diastole, and just before the systole-
a space of time which is, therefore, appropriately called the presystole
-the auricles contract, and the blood passes from them through the
mitral and tricuspid valves into the left and right ventricles. If, now,
either of the four great orifices of the heart is so narrowed by disease
as to offer an obstruction to the free progress of blood when going in
its proper direction, a murmur is produced which we naturally call
obstructive, and the lesion indicated is obstruction or stenosis. If, on
the other hand, one of the valves, which, in health, closes perfectly
to prevent reflux or regurgitation of the blood into the cavity from
which it had just come, is so perforated or puckered by disease as to
be incompetent to fit tightly and to close entirely the opening which
it ought to guard, more or less of the column of blood flowing back-
wards—in the wrong direction-it causes a murmur which we naturally
call regurgitant, and the lesion indicated is incompetency or insufficiency
of the valve. Thus, theoretically, we have eight different valvular
diseases of the heart: aortic obstruction (or stenosis), aortic regurgi-
tation (or insufficiency), mitral obstruction, mitral regurgitation, pul-
monic obstruction, pulmonic regurgitation, tricuspid obstruction, and
tricuspid regurgitation. Fortunately, however, for the brains of stu-
dents and physicians, the diseases of the valves of the right side of
the heart, with the exception of tricuspid regurgitation, are so exceed-
ingly rare, that they demand very little, if any, attention. It will be
noticed that mitral and tricuspid regurgitation are systolic, while
aortic regurgitation is diastolic, and that aortic obstruction is systolic,
while mitral obstruction is presystolic. The easiest and surest way
to decide the rhythm of a murmur is to place one finger over the
heart, and feel its impulse while the murmur is heard through the
stethoscope. If that is impracticable, the radial or carotid pulse
(better the latter, because nearer the heart) will do, making the proper
allowance. As to the diffusion of murmurs, the aortic obstructive is
apt to be transmitted upwards into the carotids; the aortic regurgitant
downwards over the sternum and along the spine; the mitral regurgi-
tant over the superficial cardiac space, and also to the left side and
back near the angle of the scapula, if not too feeble; while the mitral
obstructive and tricuspid regurgitant are confined to the superficial
cardiac space. Whenever a murmur is heard, it should be followed
up until its place of maximum intensity is reached. Two, or more,
murmurs showing valvular trouble may coexist, and may be differen-
tiated by rhythm, place of maximum intensity, quality and pitch.
Valvular lesions sooner or later produce hypertrophy and dilatation,
so that evidences of these conditions of the heart must always be
sought for.
PHYSICAL DIAGNOSIS.
67
Thoracic Aneurism.-Over such a tumor a systolic murmur is fre-
quently heard, soft or harsh or roaring, and of variable intensity.
The blood passing out of the sac may also, but not nearly so often,
cause a diastolic murmur. The heart sounds over an aneurism are
more or less intense.
PHYSICAL EXAMINATION OF THE LARYNX
(LARYNGOSCOPY).
This is the art of examining the interior of the larynx in the living
human subject by means of an image reflected from a mirror intro-
duced into the fauces. For this purpose sufficient illumination is
necessary; the same little laryngeal mirror serving to throw the rays
of light downwards into the larynx and also to bring back to the eye
of the observer a clear picture of the vocal cords and their surround-
ings. The illumination may be accomplished by natural or by arti-
ficial light. Undoubtedly the rays of sunlight, either directly entering
the mouth (not often possible) or reflected from a plane mirror, give
the brightest and most satisfactory image; but as this source of light
is only available for a part of each day, and is then constantly shifting,
and is also frequently cut off by clouds, in actual practice it is not
satisfactory. It is possible also to make use of diffuse daylight re-
flected by means of a large concave mirror, especially that from a
northern sky on a bright day. In either case, the patient should sit
with his back turned obliquely to the window and the observer oppo-
site him, the light passing over the patient's shoulder to the reflector,
from which it is projected on to the laryngeal mirror.
Practically, however, laryngoscopists almost invariably use some form
of artificial light, because it is always available in any room by day or
by night, is always constant and is easily managed. To be sure, the
image, as seen with the usual gas or oil lights, appears redder or more
yellowish than with natural light, but proper allowance can easily
be made; more easily in fact than if sometimes one kind of light
and sometimes another is employed. Artificial illumination may be
used in two ways: either the light may be directly thrown into the
patient's mouth or it may be reflected in. The former method is com-
mon in France, but the latter is greatly preferred in the United States,
England, and Germany. For concentrating the rays of the direct arti-
ficial light a convex lens is interposed, and the lamp is placed on a
narrow table between the patient and observer, the flame being, of
course, on a level with the patient's mouth. Most of us, however, are
more interested in the reflected artificial light. For this purpose almost
any lamp giving a bright steady light will do, but the best is the com-
mon so-called German study lamp, which can be raised or lowered on
68
A SYSTEM OF MEDICINE.
a rod at will, or an argand gas-burner constructed on the same prin-
ciple. Dr. Mackenzie's rack-movement laryngoscopic lamp (with bull's-
eye condenser), which readily admits of horizontal and perpendicular
motion, is a very ingenious contrivance now much used. Of this there
are different modifications for oil and gas. For strengthening the light,
some form of concentrator with one or more convex lenses is generally
used. Tobold's is perhaps the best. To this can be very readily
attached by joints moving in all directions the reflector, which is a
circular, concave mirror about three and a half inches in diameter,
having a focal length of twelve inches or more. In the office this is by
far the most convenient arrangement, but it is often desirable to attach
the reflector by an elastic band to the operator's head, either on the
forehead, or in front of the nose and mouth, or opposite one of the
eyes (there being a hole bored through the centre)-in the latter case.
it being sometimes attached to a spectacle-frame. When used on the
head a ball-and-socket joint is necessary. The laryngeal mirror (always
plane) is round, oval or square in shape, a round mirror of about four-
fifths of an inch in diameter being most useful, although the sizes run
from a half inch to an inch, and a little more. It is mounted in a
narrow metallic setting, and attached at an angle of 120° to a metallic
stem, the other end of which is screwed into a wooden handle, the
entire instrument being about eight inches long. When the tonsils are
enlarged, a small circular or oval mirror will have to be used.
The method of examination is as follows: The patient, with his head
slightly thrown back, should sit erect, opposite to the observer, and
near enough to enable the latter to see distinctly the back of the throat.
The lamp, with its light-concentrator, should be on the right of the
patient, the flame being on a level with his ear. The reflector, whether
attached to the lamp, to the concentrator, or to the observer's head,
should now be brought forward into such a position that a disk of light
will be thrown into the mouth, its centre corresponding with the base
of the uvula. It is very important that this should be thoroughly ac-
complished before proceeding further. When it is satisfactory, the
patient should be requested to open his mouth more widely, and to
put out his tongue. This should in all cases be voluntarily protruded
—not drawn out-and should be seized by the operator between the
finger and thumb of the left hand, protected by a handkerchief, towel,
or glove. The greatest gentleness should be used, and the tongue
should not be pulled on too hard. The patient can often hold his own
tongue-indeed this method is generally to be preferred-and some-
times it does not need to be held at all, if its back can be voluntarily
lowered. The laryngeal mirror should now be warmed a little over
the lamp (to prevent the condensation on it of the moisture of the pa-
tient's breath), and then tested on the back of the hand to make sure
that it is not too warm for introduction. Held like a pen in the right
PHYSICAL DIAGNOSIS.
69
hand, it is now carried steadily backward, without touching the tongue
or the hard palate, until its posterior surface rests slightly on the base
of the uvula, which should be gently pushed upwards and backwards,
the plane of the mirror forming an angle of about 45° with the horizon,
and the little finger of the observer resting for support against the cheek
or jaw of the patient. A part of the larynx will now probably come
into view, but the mirror may have to be shifted a little to one side or
the other, upwards or downwards, according to circumstances, without
being moved, however, from its position against the uvula. A very
good woodcut illustrating the different positions, manipulations, and
instruments required may be found on page 710 of Helmuth's Surgery.
Many persons bear the examination remarkably well, but others only
with difficulty and after long practice. In most cases it is advisable
to hold the mirror in the throat only for a minute or two at a time;
and when there is much sensitiveness, it is far better to let it remain
only for a few seconds, and subsequently to introduce it again, than to
excite choking and retching by keeping it in longer, only to prevent
further examination at the same sitting. Repeated manipulation,
however, greatly lessens the sensitiveness of the parts. If the back of
the tongue will not stay down, the patient should take several deep
inspirations, or should make some vocal sound, such as "ah," "eh,"
"oh," etc. A tongue depressor is rarely needed, and should only be
employed as a last resource. The tongue should not be pulled too far
forward in such cases, and the patient should not strain. Excessive
irritability of the fauces is very often caused by the clumsiness or in-
experience of the practitioner. If not due to this cause, it may often
be overcome by sucking small pieces of ice for fifteen or twenty minutes
continuously, or by a strong effort of will on the part of the patient.
If the epiglottis is unusually large or pendent, the patient should laugh
or produce falsetto notes. If it is not then raised sufficiently, the
mirror should be introduced lower in the fauces, and should be held
more perpendicularly. A great deal of patience as well as aptitude is
often required on the part of the examiner. For an explanation of the
proper use of laryngeal forceps and other instruments, special mono-
graphs should be consulted.
The laryngeal image in health is well represented by the two accom-
panying woodcuts from Mackenzie. The first shows the vocal cords
drawn widely apart, and the position of the various structures above
and below the glottis during quiet inspiration; and the second shows
the approximation of the vocal cords and the position of the various.
parts in the act of vocalization. In these figures ge represents the
glosso-epiglottic folds, u the upper surface of the epiglottis, its lip, c
its cushion, v the ventricle of the larynx, ac the ary-epiglottic fold, c W
the cartilage of Wrisberg, cS the capitulum of Santorini, com the ary-
tenoid commissure, vc the vocal cord, vb the ventricular band or false
70
A SYSTEM OF MEDICINE.
vocal cord, pv processus vocalis, er cricoid cartilage, t the rings of the
trachea, fi the fossa innominata, hf the hyoid fossa, ch the cornu of the
hyoid bone, and a the arytenoid cartilages. In expiration, the vocal
cords approach each other, but not so closely as in vocalization. It
must be remembered that, owing to the reflection, there is an apparent
inversion of parts, but this is only in the antero-posterior direction.
As the mirror is usually held, the arytenoid cartilages, for instance,
which are at the back of the larynx, are seen at the bottom of the
mirror, while the epiglottis and base of the tongue are seen at the top
of the mirror. The image appears in a plane nearly vertical, while
the structures themselves are more nearly in planes horizontal to the
vertical axis of the body, although not all on the same plane. When
the image is transferred to paper, the antero-posterior inversion is.
more complete. Here the epiglottis and the anterior insertion of the
ge
u
FIG. 3.
ge
ge
FIG. 4.


ע
ve
de
v b
fi
cw
· p v
c S
hf
com
ch
CW
c S d
pv
oom
vocal cords, which in reality are nearest the observer, seem in the pic-
ture to be the farthest, and the arytenoid commissure, really farthest,
seems nearest. There are no lateral or vertical inversions, however.
The patient's right vocal cord is seen on the right side of the mirror,
which, of course, corresponds with the left side of the observer. This
is quickly comprehended by one who is used to the percussion and
auscultation of the chest. Vertically, also, the epiglottis, which is
really highest in the larynx, is highest in the mirror.
As to the normal color of the different parts, the upper surface of
the epiglottis is of a dirty pink, its lip is yellow, and its cushion is
always bright red; the ary-epiglottic folds are like the gums, and the
cartilages of Santorini and of Wrisberg are of a somewhat brighter red;
the ventricular bands, or false vocal cords, look like the lining of the
lips; the cricoid cartilages and the tracheal rings are yellow, and the
mucous membrane between them is bright red. The vocal cords, which
are by far the most important objects to examine, are glistening and
pearly white like a child's conjunctiva, at one point only, close to the
arytenoid cartilages, presenting a yellowish spot as large as a pin's
head.
It is very interesting to study the vibration of the vocal cords while
PHYSICAL DIAGNOSIS.
71
the patient sings, it being confined to their edges when the higher notes
(especially falsetto) are sung, but extending over their whole surface
when the lower notes are sounded. They are sometimes covered with
clear mucus, which prevents a good view, but this may usually be
expelled by a few slight coughs.
It is not until the observer has, by repeated examinations of the
healthy larynx, acquired some dexterity in manipulation and a prac-
tical acquaintance with the shape, color, and movements of its parts,
that he is fitted to recognize the abnormal modifications which occur
in its various diseases. The principal of these modifications to be
looked for are congestion, swelling, ulceration, and exudation, such as
are found in inflammation, oedema, tubercular and syphilitic troubles,
etc.; different forms of intra-laryngeal growths; paralytic or spas-
modic affections of the vocal cords; and compression of the trachea.
by aneurisms or other tumors. These morbid appearances will be
described in connection with the diseases mentioned.
PHYSICAL EXAMINATION OF THE NARES (RHINOSCOPY).
By this term is generally meant inspection of the posterior nares
and adjacent parts by means of reflected light. The same apparatus
as for laryngoscopy is required, and the same principles are involved.
Here, however, the mouth-mirror, which is to be placed under, or be-
hind, the soft palate and uvula, is to be directed forwards and up-
wards, and the maximum of illumination should be a little lower than
for laryngoscopy. The manipulations are more difficult than in the
latter, although in most cases with patience a satisfactory examina-
tion can be made. When about to introduce the mirror, the patient
should be instructed to open his mouth and breathe through his nose
exclusively. This secures more room by enabling the soft palate to
hang free from the posterior wall of the pharynx. If the patient
breathes through his mouth, as he is apt to do when it is open, the
soft palate becomes more or less closely applied to the wall behind it
and cuts off communication with the nasal passages. If he is unable
to continue breathing in this way, it has been suggested that he repeat
nasal sounds like the French en, which forces the palate forward and
causes the velum to drop. In spite of both of these measures, no
matter how intelligent the patient may be, he will sometimes have to
be requested to practice alone before the looking-glass for a long time
before he succeeds in letting the palate hang free. Dragging the palate
forward forcibly by means of a broad and flat hook passed behind it
has been resorted to, but is very unsatisfactory on account of the vio-
lent spasmodic action of the palatal muscles caused. A late device
(Lancet, July 28th, 1883) is a piece of soft red rubber tubing, an eighth
72
A SYSTEM OF MEDICINE.
of an inch in diameter, gently passed into one nostril till the tip end
is just visible below the soft palate, when it is seized with forceps,
drawn out through the mouth, and loosely tied over the upper lip to
the end protruding from the nose. This loops the soft palate upwards
and forwards, and draws it away from the pharyngeal wall. It may
be done on one side only, or on both at the same time, and is said to
cause very little annoyance to the patient.
The use of a tongue depressor is almost always required to gain
additional room for observation and manipulation. A common
laryngoscopic mouth-mirror (generally of the smaller sizes) is better
for rhinoscopic examination than those sometimes recommended (and
5
6-
7
8
9.
10
FIG. 5.
1
10

9
5
7
8
11
Rhinoscopic Image.-1, nasal septum; 2, nasal passages; 3, superior meatus; 4, middle meatus;
5, superior turbinated bone; 6, middle turbinated bone; 7, inferior turbinated bone; 8, pharyn-
geal orifice of Eustachian tube; 9, fossa of Rosenmueller; 10, glandular tissue in vault of phar-
ynx; 11, posterior surface of velum.
made on purpose), where the glass is attached to the stem at a right
angle. By depressing or raising the handle a good view can be ob-
tained of all parts. It is always necessary to remember that, owing
to intervening structures, we never see the reflection when the mirror
is exactly behind the nares in a vertical plane, and that the picture
which we do see in the mirror is only an image in perspective. On
this account it takes some time to get a true idea of the proper relation
of the parts. When a large mirror cannot be used, a small one may
be passed first on one side and then on the other, in order to view the
parts successively. In a rhinoscopic mirror can be seen the posterior
surface of the soft palate and uvula, the posterior and part of the
lateral portions of the septum of the nose, the turbinated bones, the
nasal meatuses, the roof of the pharynx and its walls, and the orifices
of the Eustachian tubes.
Anterior rhinoscopy by means of the little mirror is possible, but
the amount of reflecting surface is necessarily so small that it is un-
satisfactory. The best method of examining the anterior nares is that
of direct inspection when illuminated by daylight or by artificial
PHYSICAL DIAGNOSIS.
73
light thrown in by a concave reflector. To dilate the nostril, different
forms of specula are used, such as the common ear specula, Thudi-
chum's, Fraenkel's, Elsberg's trivalve, and Duplay's bivalve, the last
looking like a vaginal speculum. A bent hairpin makes a very excel-
lent retractor for pulling aside the nostril. The following parts can be
seen the whole anterior portion of the nasal cavity from the superior
turbinated bone to its floor; the anterior parts of the middle and infe-
rior turbinated bone; the surface of the septum; and generally the
greater part of the inferior meatus of the nose. If the latter is large
enough, the posterior wall of the pharynx may be seen through it.
The turbinated bones, in health, are of a pale red color, and are
usually covered with a mucous secretion, which may vary consider-
ably, within normal limits, in amount and color. This may be washed
away with a syringe, if abundant enough to interfere with the vision.
The principal morbid appearances to be looked for in an anterior rhi-
noscopic examination are changes in color and in configuration, swell-
ings or hypertrophies, an extra amount of secretions, ulcerations, etc.
Palpation, or exploration with the finger and probes, may be resorted
to after the eye has seen what it can. The finger-nail should not be
too long; and if, on the other hand, apprehension is felt that the
patient may suddenly bite, the jaws may be kept open by a piece of
wood between the back teeth. The forefinger should be carried into
the mouth, palmar surface upward, until it reaches the soft palate,
behind which it should be insinuated carefully. It should not be
allowed to remain too long, as the feeling is very disagreeable and
vomiting is easily induced. Repeated examinations, however, gradu-
ally deaden the sensibility. By passing in the finger with the palmar
surface downwards, the epiglottis and the upper portion of the cavity
of the larynx may be explored. Threatening spasm or vomiting
should be a warning to desist immediately. Exploration of the
nose in front or in back may also be made by blunt-pointed probes or
sounds, suitably bent, under the guidance of sight, if possible. By
oiling the little finger and passing it into the nostrils, the position of
ulcers, tumors, and foreign bodies can sometimes be ascertained very
accurately. The examiner must not forget the simple procedure of
inducing the patient to close the mouth and one nostril and to blow
through the other, in order, by the sound, to detect a possible narrow-
ing of its calibre by some obstruction. The latter would be very apt,
also, to alter the sound of the patient's voice.
PHYSICAL EXAMINATION OF THE ABDOMEN.
While it is undoubtedly true that the physical methods of explora-
tion often afford us more help than symptomatology in the diagnosis
of abdominal affections, yet, as a rule, we cannot here expect to attain
74
A SYSTEM OF MEDICINE.
the same accuracy and to secure as perfect results with these methods
as in the diagnosis of thoracic diseases. Some of the difficulties to be
encountered are as follows: In diseases of the chest we have to ex-
amine only the heart, lungs, and the great blood vessels; whereas, in
diseases of the abdomen, we may be obliged to examine a dozen dif-
ferent organs before we can arrive at a decision. Again, in health the
thoracic organs act in a rhythmical and regular manner, about the
same amount of air entering the lungs and the same amount of blood
entering the heart, other things being equal, from one minute to an-
other; whereas the abdominal viscera often act in an irregular and
intermittent manner, and their contents vary greatly from time to
time. At one examination either the stomach, bowels, or bladder, for
instance, may be full, and empty at another examination on the same
day. Necessarily, the physical signs will differ. Again, the virgin
uterus occupies a very small space and escapes detection either by
percussion or by external palpation; but in the latter months of preg-
nancy the womb dwarfs into insignificance every other abdominal
organ. Such circumstances always make a diagnosis of abdominal
more doubtful than one of thoracic disease; in spite of these difficul-
ties, however, much can be learned by a careful attention to the
methods which will now be described. The different regions of the
abdomen and their contents have already been explained on page 48,
in connection with the regions of the chest. In thoracic disease, aus-
cultation is by far the most important of the physical methods; in the
diseases we are now to consider, it holds a low rank. Here percussion.
and palpation give us the most valuable assistance.
Inspection of the Abdomen.-By inspection we notice alterations.
in its shape and movements. The patient should lie on his back with
his thighs slightly flexed. It is necessary to remember the variations
which are possible in a normal state. In children, and often in old
persons, the abdomen is larger in proportion to the size of the chest.
than in others, and it is more voluminous and broader inferiorly in
women than in men. Besides this, we notice that people in health
differ greatly from each other in the size of the abdomen. Where
there is pathological change, however, in connection with change in
size, other signs are very apt to attract our attention, such as emacia-
tion elsewhere, alterations of the color of the skin, distension of the
superficial abdominal veins, oedema of the feet and legs, etc.
In disease the abdomen may appear to the eye to be distended or
retracted. If distended, the enlargement may be general or partial. It
is general in cases of ascites; also from œdema of the abdominal walls,
from gas in the intestines, or from large tumors which fill up the en-
tire cavity. In ascites the smooth, uniform swelling of the abdomen,
unless the tension is extremely great, will change somewhat with
changes in the position of the patient, because fluid will seek its level.
PHYSICAL DIAGNOSIS.
75
If he lie on one side, it lessens in the upper flank and increases in the
lower; if he stand, it is most apparent in the lower half of the abdo-
men; if he lie on his back, it projects less forward, but gains in breadth.
If there is an accumulation of gas in the intestines or in the peritoneal
cavity, no change is produced by change of posture. If the abdomen
is very greatly distended from any cause, its skin looks shining,
anæmic, and somewhat blue, and where the stretching is greatest,
white lines are seen. These latter are oftenest exemplified in cases of
pregnancy. The superficial abdominal veins are rendered prominent
when the pressure interferes with the return of blood through the vena
cava inferior, or else (as in cirrhosis of the liver) through the portal
system. When the enlargement of the abdomen is partial, it is gen-
erally owing to increased size of its organs, such as the liver, spleen,
uterus, or ovaries. If the liver is moderately enlarged, a prominence
sometimes appears on the right side in such a way as to render some
of its outlines easily distinguishable, especially if the skin is thin and
the parts are viewed in profile. Sometimes, however, the enlargement
is so enormous, as in certain cases of cancer, hydatid cysts and amy-
loid degeneration, that the whole or a greater part of the abdominal
cavity is pretty uniformly filled up. If the spleen is much enlarged
from intermittent fever, amyloid degeneration, or leukæmia, a promi-
nence on the left side may indicate its position; but this organ, like-
wise, may be so enormously increased in size as to fill up the greater
part of the abdominal cavity, and here, too, the enlargement therefore
ceases to be partial and becomes general. If the stomach be dilated
with gas, an oval-shaped swelling may appear in the epigastric region,
extending a little towards the left. In rare cases the dilatation may
be so excessive as to render the whole abdomen prominent. Cancer
of the stomach, which oftenest affects the pyloric end, will sometimes
appear as a circumscribed elevation in the epigastrium. A large fæcal
accumulation in the colon may show as an elongated and often mova-
ble tumor in the right or left iliac region. The peristaltic action of
the bowels may be excited or increased by rubbing the surface of the
abdomen, and will become visible if the patient is not fleshy. If there
is a stricture of the intestines, this movement will be seen only above
the contracted part. Tumors of the uterus, either pathological or
physiological (pregnancy), if not too large, generally keep pretty near
to the middle line of the abdomen. Tumors of the ovaries, on the
other hand, until they acquire considerable size, appear either in the
right or left groin; afterwards they may become large enough to fill
up the whole of the abdomen and distend its walls uniformly, so that
if not seen until late it may be impossible to tell from which side they
originally sprang. Cancer of the kidneys and hydronephrosis, if seen
at all (which is rare), first appear in the lumbar region, and after-
wards, when large, extend to the front of the abdomen. It is some-
76
A SYSTEM OF MEDICINE.
times possible, though very uncommon, to see the swelling produced
by a movable kidney. The bladder, distended with urine, on the
other hand, is easily recognized as an oval-shaped swelling above the
pubes. Other causes also may produce partial and visible enlarge-
ment of the abdomen, such as swelling of the mesenteric glands,
tumors of the omentum, and other tumors, hernias, crowding of the
abdominal organs by some chest diseases, etc.
Retraction of the abdominal walls as a rule affects equally the whole
surface, and is seen where the bowels are almost or entirely empty,
as a result of stricture of the oesophagus, cancer of the pylorus,
stenosis of the small intestines, or chronic diarrhoea and dysentery.
It is also noticed in lead colic, and particularly in the tubercular men-
ingitis of children, and in general emaciation from any cause.
The movements of the abdominal walls should also be inspected.
They are greatly increased during respiration in pleurisy, pneumonia,
pericarditis, etc., but greatly decreased where there is much abdom-
inal pain, as in peritonitis. A distinct pulsation is often visible in
the epigastric region which sometimes is, and at other times is often
mistaken for, aneurism; and the heart's pulsations are sometimes
communicated to large peritoneal effusions of fluid, appearing on the
surface as distinct waves. The abdominal muscles, lastly, are often
seen to contract and relax spasmodically. By means of the vaginal
speculum very important information in regard to uterine diseases is
obtained by inspection, and by the anal speculum in a similar manner
diseases of the lower bowel are brought into view.
Mensuration of the Abdomen. In this method a graduated
tape is used. By it accurate records can be made, from time to time,
of the amount of increase or decrease of abdominal dropsies, of
ovarian or other tumors, accumulations of gases, etc.
Palpation of the Abdomen.-In making an examination of the
abdomen this method becomes very important. By it we can deter-
mine the size, form, consistency, and position of the abdominal viscera,
as well as of tumors or other abnormal substances; we can ascertain if
what we feel is tender, whether it is movable, whether it has a motion of
its own, whether it is smooth or nodulated, whether it fluctuates, etc.
The patient should generally be placed on his back, with thighs flexed
and head bent forward, so as to relax the abdominal muscles; some-
times, however, important information is gained by placing him on
one side also, as, for instance, where we desire to discriminate between
an aneurism and a tumor lying over the aorta. Besides an occasional
thick layer of fat or oedema, the greatest obstacle to palpation is the
resistance of the recti, which are more particularly excited to contract,
if the patient is poked with the ends of the fingers. The whole hand,
therefore, warmed, should be evenly applied to the skin, and the
fingers then depressed in different directions. The contraction of the
PHYSICAL DIAGNOSIS.
77
recti sometimes causes what is called a phantom tumor, which disap-
pears under ether. To prevent the fixation of the diaphragm, the
patient should be induced to talk or to count as long as possible with-
out taking a new inspiration. Palpation is naturally easiest in ema-
ciated persons and women who have borne children. The pulsation
of the abdominal aorta in them is very easily felt in the middle line.
Palpation of the Liver.-In health the presence of this organ
under the margins of the ribs can be detected by the touch only with
difficulty, and this merely during deep inspiration. Any enlarge-
ment, however, is easily felt (provided ascites is not present), its sharp
edge, and sometimes also a considerable part of its surface, coming
within reach. Not much more than an increased sense of resistance
is felt with passive congestion, acute hepatitis, fatty infiltration, reten-
tion of bile, etc.; but with amyloid or waxy degeneration and hydatid
cystic disease the enlarged outlines and surfaces are very easily grasped;
and in cancer and leukæmia, these enlargements often filling up such a
large proportion of the abdominal cavity, the fingers have free oppor-
tunity to explore. Pressure over the liver gives no pain in fatty liver,
amyloid liver, and hydatid growths, but palpation in all inflammatory
conditions is painful, and it is particularly so in cancer. The surface
of the enlarged liver is smooth in hyperæmia, biliary engorgement,
fatty and amyloid degeneration; but it is nodulated in cancer, save of
the diffuse variety. In consistency, acute swellings are softer than
chronic, and of the latter the fatty liver is softer than the amyloid. Cir-
rhosis, which is really the hardest of all, cannot be reached by the finger.
In shape, the greatest deformity of the liver is caused by cancer and
hydatid growths, the enlargement in other diseases being generally
uniform. A tremulous sensation on rapping, called hepatic fremitus,
has been described by some as characteristic of hydatid growths or
echinococcus tumors, but the majority of those who have seen the
disease fail to find it or confuse it with fluctuation. In this country
the affection is so extremely rare that it need not give us much con-
cern. Fluctuation can be felt over large hepatic abscesses, which,
though rare in this climate, are far more common than hydatids.
Ascites, causing fluctuation, may or may not accompany hepatic
cancer. The liver may be displaced and pushed downwards by tight.
lacing, by pulmonary emphysema, by right pleural effusion or pneu-
mothorax. In certain rare cases of relaxed ligaments also, it hangs
down as a movable or wandering" liver. In these cases the organ
can be felt projecting from under the ribs as well as when it is en-
larged. The differentiation is made by percussing its upper border,
which is in its proper place in enlarged, but lowered in displaced
liver.
Palpation of the Gall-bladder.-The gall-bladder, if fully dis-
tended with bile, but not otherwise, may often be felt as a moderately
78
A SYSTEM OF MEDICINE.
elastic, rounded tumor, attached to the margin of the liver near the
ninth costal cartilage, outside the edge of the right rectus muscle.
Pressure, by expelling bile, may diminish the tumor. The gall-
bladder may be dilated and sometimes enormously enlarged by an
accumulation in it of pus or muco-serum. If this swelling is painful
and tender on pressure, it may be discriminated from peritonitis by
the unequal enlargement of the abdomen, and from ovarian disease
by its being continuous with the liver and moving with it during
forced inspiration and expiration.
Palpation of the Spleen.-In the great majority of cases the
normal spleen cannot be reached with the finger; exceptionally, if
the person is very thin and the skin is soft and yielding, and the
patient lies on his right side, it may be felt at the end of a full inspira-
tion deep in the left hypochondrium. Even in the lesser degrees of
enlargement, however, it may usually be detected under these cir-
cumstances by an increased sense of resistance at least, although, even
if it 'swell to twice its natural size, it seldom emerges from under the
costal arch. Slight enlargements occur in typhus, typhoid and re-
lapsing fever, pyæmia, small-pox, obstruction of the portal circula-
tion (as in cirrhosis of the liver and mitral lesion), etc. In old inter-
mittent fever and in amyloid degeneration the spleen may acquire a
much greater size; but leukæmia is the disease which particularly
augments its volume, it sometimes becoming here so enormous as to
fill half or more of the abdominal cavity. In enlarging it always ex-
tends obliquely downwards and inwards toward the median line, gen-
erally preserving its original shape. The notches or depressions are
deepened so much by the swelling that they serve for valuable diag-
nostic landmarks in excluding other tumors, being easily made out.
In consistency acute swellings of the spleen are soft, but all the chronic
and large swellings are hard. On palpation they are all smooth and
painless. A movable or wandering spleen is occasionally met with, its
dislocation being due to relaxation of its ligaments. It can be diag-
nosticated by palpation, as it lies near the surface, its upper end being
oftenest situated just under the border of the costal arch. The spleen
may be pressed down also by pleuritic effusion, pneumothorax or
emphysema. A splenic tumor is leukæmic, if under the microscope
a large increase in the number of white blood-corpuscles appears; it
is probably amyloid if the patient have a disease in which this degen-
eration is common, and malarial if intermittent fever has pre-existed.
Hydatid disease and cancer are very rare.
Palpation of the Stomach.-Great tenderness on pressure over
a circumscribed area occurs particularly in gastric ulcer and cancer,
being almost uniformly present in them; but as it occurs in some
degree also in most other affections of the stomach, too much stress
should not be laid on it as a diagnostic point. The greatest aid ren-
PHYSICAL DIAGNOSIS.
79
dered by palpation in diseases of the stomach is the detection of a
cancerous tumor, whose nature indeed only becomes certain by means
of palpation in connection with the proper symptoms, and which, when
far enough advanced and situated at the pylorus (as it usually is), can
almost always be felt as a firm, smooth or nodulated, round, oval or irreg-
ular, fixed or movable lump, easily grasped and readily separated from
the surrounding viscera. It is oftenest felt in the right epigastrium, one
or two inches below the costal cartilages, but is sometimes dragged
downwards by its weight and by the attending dilatation of the
stomach, though not by a deep inspiration. Owing to the different
degrees of distension of the stomach, it is more easily felt on some
days than at others. Cancer of the cardiac end of the stomach or of
the smaller curvature is too deeply seated to enable us to reach it
with the finger. An epigastric tumor is not always cancerous, but
may be exceptionally a myoma or sarcoma of the stomach. It must
also be discriminated from cancer of the left lobe of the liver, aneurism
of the abdominal aorta, fæcal accumulation in the transverse colon,
and enlargement of the pancreas.
Palpation of the Intestines.-Light pressure is well borne in
inflammation of the mucous membrane of the bowels, but the patient
shrinks from strong pressure. On the contrary, very gentle pressure
on the surface causes pain in hyperesthesia, while deep pressure
causes little inconvenience if the attention of the patient is distracted
by conversation or otherwise. In peritonitis the pain is more in pro-
portion to the force used, being appreciated with the slightest touch
and becoming intolerable with firm pressure. Neuralgic or nervous
pains, such as that of colic, unlike those connected with inflammation,
are generally relieved instead of being increased by pressure. In
typhoid fever, inflammation of the cæcum, and of its appendix, there
is decided tenderness on palpation in the right iliac region, and in in-
flammation of the appendix cæci palpation sometimes discovers a
semi-solid tumor formed from the exudation, perhaps almost as large
as the fist, and sharply defined from the neighboring parts. In
typhoid fever the splashing of fluid, which when heard is called gurg-
ling, can be felt also in the same region; in Asiatic cholera, where the
bowel frequently contains an enormous amount of fluid, and even in
simple intestinal catarrh, the same sensations are felt all over the
abdomen. Large, hard fæcal accumulations in the intestinal canal
can be felt, and should not be confounded with enlargement of organs
or with tumors. They are generally found on the right or left side of
the abdomen, oftener on the left side in the descending colon, although
they may sometimes occupy a good part of the ascending and trans-
verse, as well as of the descending colon. In uncertain cases large in-
jections given through a flexible tube, or saline purgatives will often
remove the doubts and the fæcal tumors simultaneously, but some-
鳊
​80
A SYSTEM OF MEDICINE.
times these measures fail to dislodge them. On such occasions re-
liance must be placed on their peculiar feeling. They seem hard and
resistent, but if one finger be steadily pressed on them for a few min-
utes, they will finally (if not enteroliths) indent like a hard snow-
ball, the indentation being permanent. The masses themselves are
irregular, movable, and not usually tender. Cancer in the duodenum
cannot be differentiated from cancer of the stomach. Cancer of the
rectum can be recognized by the finger introduced. Cancer of other
parts of the intestines can be decided upon if, with the proper symp-
toms, a tumor be felt, which is tender, nodulated, and of irregular
shape. This, in the small intestines and transverse colon, is movable,
unless adhesions have followed peritonitis, but at the sigmoid flexure
and cæcum it is fixed. At the latter place it may occasion obstruc-
tion, and fæcal accumulation above the tumor will apparently add
to its size. In such cases the peristaltic movements of the bowel can
be felt above the stricture. Cancer of the peritoneum may be in the
form of disseminated nodules and escape detection by palpation, or
of one or more fixed or movable, nodulated tumors which can be
grasped, or in the form of a large, sometimes immense, gelatinous or
colloid tumor, filling much of the abdomen, and often coexisting with
ascites. From ascities alone it is distinguished by the irregular form.
of abdominal enlargement, its feeling of resistance to pressure at
points, and the limitation of fluctuation. The aspirator will help the
diagnosis. Internal hæmorrhoids can be felt by the oiled finger
passed into the rectum, and stricture of the latter can be discovered
in the same way and by the feeling of the rectal bougie. Cancerous
and other tumors of the omentum, either involving this structure
alone or involving also neighboring structures, can be felt through the
abdominal walls, but are exactly located with difficulty. Tumors of
the pancreas, generally cancerous and secondary, can be felt deep in
the epigastrium as hard and immovable bodies, but a confident diag-
nosis is impossible.
Palpation in Ascites.-This method of detecting fluid in the ab-
dominal cavity is so often and so successfully resorted to, that it de-
serves special consideration. Fluctuation, as it is called, is obtained
by placing one hand lightly on the abdomen and giving a smart rap
with the fingers of the other hand, either near by, or on the other side;
the patient being on his back or in an upright position. A wave of
fluid is felt to roll against the applied hand, its force varying with the
amount of fluid and the consequent tension of the abdominal walls.
If the quantity is small and the walls flaccid, the patient should stand
upright, so that the fluid may distend the lower part of the abdomen,
and the hands should be used near each other. If the effusion is en-
cysted, fluctuation is lessened; it is also obscured by oedema or fat in
the abdominal walls. Sometimes, when the walls of the abdomen are
PHYSICAL DIAGNOSIS.
81
tense, without containing fluid, their vibration may be mistaken for
fluctuation; but this fallacy may be prevented if the hand of a third
person is applied edgewise on the abdomen between the physician's
hands.
Palpation of the Kidneys.-As a rule, in health, the kidneys
cannot be felt, especially in fat people. They lie near the spinal
column, in the space corresponding to the two lower dorsal and the
two upper lumbar vertebræ (the right being a little lower than the
left), imbedded in fat and resting on the lumbar muscles. Above the
right kidney is the liver, above the left the stomach, and above both
the colon and intestines. To feel for the kidney, the patient being on
his back with thighs flexed, the physician should stand on the side
opposite the kidney to be examined, and should place one hand on
the mid-flank behind and below the last rib, and the other over the
proper part of the abdomen in front, trying to approximate them suffi-
ciently to bring the kidney between, the patient, meanwhile, being
instructed to take a deep expiration. Tenderness and enlargement
can thus be detected. Decrease in size is beyond the reach of physical
exploration to determine. The kidneys may be enlarged by hydrone-
phrosis, pyonephrosis, renal and perinephritic abscess, hydatid and
other cysts, cancer, tubercle, simple hypertrophy, etc. In hydrone-
phrosis, where the pelvis of the kidney is dilated and filled with urine,
whose outflow is prevented by some obstruction, a large, undulating,
often fluctuating, lobulated mass is found in the lumbar region, not
tender to the touch, extending upwards, downwards, and forwards,
sometimes suddenly disappearing coincidently with a large passage
of urine. When existing on one side, as is usually the case, the
tumor may grow very large; in one case reported it containing sixty
pounds of fluid, and occupying the whole abdominal cavity. They
can, of course, never attain great size when affecting both kidneys.
The tumor of hydronephrosis may be confounded with an ovarian
growth, ascites, hydatids of the kidney, or perinephritic abscess. In
pyonephrosis the physical signs are about the same, except that there
is tenderness on pressure. Both renal abscess and perinephritic ab-
scess also form a painful tumor in the lumbar region on one side.
Palpation is insufficient to differentiate them; the symptoms and the
history of the case must be considered. Renal cysts in enlarged kid-
neys form soft, but not fluctuating, movable tumors, without pain or
tenderness, in the lumbar region, extending also into the abdomen, if
large enough, in persons over thirty years of age. Unlike hydrone-
phrosis, the tumor does not suddenly change in size. It differs also in
being almost always bilateral, although one kidney may be very much
larger than the other. Dr. Roberts reports a case of this affection
where one kidney weighed sixteen pounds, its length being fifteen
and one-quarter inches, and its breadth nine and one-half inches.
VOL. I.-6
82
A SYSTEM OF MEDICINE.
Hydatid cysts, almost unheard of in this country, although common
in Iceland, are unilateral. They cannot be differentiated by palpa-
tion from hydronephrosis. Tubercle rarely causes much enlargement
of the kidney. Primary cancer of the kidney, generally encephaloid
and unilateral, a rare disease, occurs mostly in children and very old
people, often forming a large and sometimes an enormous tumor, fill-
ing the abdominal cavity. Roberts reports one weighing thirty-one
pounds. The tumor extends towards the umbilicus, is oftener on the
right than on the left side, is generally immovable from peritoneal
adhesions, does not descend with inspiration, does not fluctuate, is
not always tender, is irregular in surface, and is soft at some points
and hard at others. On the right side it can be distinguished from
enlarged liver by the possibility of pressing the fingers between them;
and on the left from enlarged spleen, by its immobility and the ab-
sence of the distinctive notch of the latter. Movable or floating kid-
ney, generally acquired, occurs oftener on the right side, and oftener,
also, in women. If the abdominal walls are not too thick, it can gen-
erally be felt with ease, and often grasped in the hand. Coming so
near the surface, its smoothness and peculiar bean-shape can be
readily made out. When pressed upon, it often slips away from the
finger on account of its mobility and smoothness. Its situation
changes with the position of the body and with the acts of respiration.
It is generally situated between the false ribs and the umbilicus, but
it may be found in the iliac fossa. Generally, palpation gives no
pain, but rough handling gives rise to uneasy sensations, nausea, and
faintness. The diagnosis is not quite so easy when, as a result of in-
flammation, adhesions have been formed which bind the dislocated
kidney down to surrounding parts, and thus interfere with its mo-
bility.
Palpation of the Bladder.-When empty, the bladder cannot
thus be recognized; but when distended, it is easily felt as a smooth,
oval, tender, firm but elastic tumor, extending up in the median line
from the pubes towards, or even beyond, the umbilicus. In infants
less distension is required to enable it to be detected by palpation, as
it lies less deep in the pelvis. It can easily be differentiated from preg-
nancy or a uterine tumor by catheterization.
Palpation of the Uterus.-When unimpregnated, the healthy
uterus cannot be felt through the abdominal walls, but generally in the
fourth and sometimes even in the third month of pregnancy, its fundus
may be felt, especially in a thin woman, above the pubes, inclining a
little to one or the other side, oftener to the right; the inclination being
due to the projection of the sacro-vertebral promontory, and to the
presence in the left side of the sigmoid flexure of the colon and the
rectum. This inclination may give rise to a suspicion of ovarian dis-
ease.
After the fifth month of gestation the pregnant uterus occupies
PHYSICAL DIAGNOSIS.
83
a central position. At the end of the fifth month the fundus is felt half-
way between the symphysis pubis and the umbilicus; at the end of
the sixth at the umbilicus; at the end of the seventh half-way between
the umbilicus and the end of the sternum; at the end of the eighth, at
the ensiform cartilage; and during the last week or two of pregnancy, it
may fall so as to be felt lower. These are the common heights to which
the uterus rises and can be felt during pregnancy, and yet there are
exceptions. Some women may seem as large at five months as others.
at seven. The variations are owing to the height of the woman, the
amount of intestinal inflation, of the prominence of the sacro-verte-
bral curve, the capacity of the pelvis, and the frequency of child-bear-
ing. Of course, the abdomen will not increase, but rather diminish
somewhat, if the foetus die, and is retained some months. During the
fourth month, the uterus feels like a soft, though firm, fleshy tumor, of
a uniform smooth surface, but afterwards loses something of this firm-
ness, and becomes obscurely fluctuating on account of the liquor
amnii. Soon the motion of the child becomes felt, and gradually its
head, trunk, and limbs become distinct enough for recognition by the
touch. If palpation is conducted per vaginam, the cervix, during the
first four months, seems to have the same form and length as usual,
but it is fuller, rounder, softer and more elastic. In the fifth month
it is shorter, and swelled out towards its upper end, especially in
front; and between this place and the symphysis pubis the enlarged
uterus can plainly be discovered, where at other times nothing is felt.
The finger now enters the os more easily, and the foetus can be de-
tected by ballottement. In the sixth month the cervix is still more
shortened, and during the rest of the pregnancy its obliteration con-
tinues to be gradually effected, so that near the end, in its place is
felt at the upper part of the vagina the distended uterus like a globu-
lar tumor. The os at nine months is reached with great difficulty,
and its margins are thin, soft, and relaxed sufficiently to admit the
finger, which feels the membranes.
Fibroid tumors of the uterus give rise to enlargement of the organ,
and are best detected by palpation. They vary in size from a millet
seed to a mass weighing fifty pounds. They are generally divided,
according to their location, into sub-peritoneal, on its outer surface,
intra-mural, in its walls, and sub-mucous, projecting into its cavity
like polypi. If large enough to be felt through the abdomen, they
have generally a hard, firm feeling without any fluctuation, with a more.
or less rounded or lobular-generally unsymmetrical-outline, with
nodules like hard balls varying in size and shape, seldom occurring
singly and of slow growth. The connection of these tumors with the
uterus is proved by means of the sound, as they move with it. If
small, they may easily be confounded with flexions of the womb or
hæmatocele, or the exudation of pelvic cellulitis. The sound (which
84
A SYSTEM OF MEDICINE.
is a prolonged finger) is here a good adjunct. When there is a tumor,
the sound generally passes more than the usual two and one-half
inches, and the course which it takes does much to locate the tumor.
Fibro-cystic tumors may grow very large, and they resemble ovarian
tumors so closely that the most experienced ovariotomist may be
deceived. They are partly solid, partly fluctuating (although not to
the same extent, usually, as ovarian tumors). The uterine sound.
enters farther, and often shows them to move with the uterus. Still,
neither palpation nor percussion can make the diagnosis positive.
Atlee, with his great experience, in his work on ovarian tumors, claims
that the fluid removed by tapping can alone decide this. It coagu-
lates on exposure to the air, and shows under the microscope elon-
gated fibre-cells like those of the uterus. For the diagnosis of uterine
displacements, the reader is referred to the appropriate chapter.
Palpation of the Ovaries.-In health, an ovary, being only an
inch and a quarter long, and hanging freely in the pelvis, cannot be rec-
ognized by the touch. To detect swelling and tenderness, pressure
should be made backwards towards the brim of the pelvis, from a
point a little above the curve of Poupart's ligament, while at the same
time two fingers of the other hand should be introduced well into the
vagina. It must be confessed, however, that it is very hard to get ac-
curate information in this way, unless the swelling has reached some
size, or, in other words, unless a distinct tumor has formed. Ovarian
tumors are the commonest of all abdominal tumors. A patient is
seldom conscious of the existence of one, until it can be felt above the
brim of the pelvis. At this time its size usually varies from a hen's
to a goose's egg, which it resembles in shape, and its position is in one
or the other groin. It is circumscribed, generally elastic, movable,
prominent, and not sensitive. As its size increases, it takes a more
central position, and sometimes the patient may not even know of its
existence until she finds a lump in the middle of the hypogastric re-
gion. One of the strongest diagnostic points in connection with these tu-
mors is, that they start from one side. With increased size the tumor
becomes less movable. If a unilocular cyst, there will be in it distinct
fluctuation; if bilocular or trilocular, fluctuation will be less distinct;
and if multilocular with very numerous cysts, fluctuation may be diffi-
cult to get, or it may be absent. Fluctuation also varies according to the
consistency of the fluid, and the thickness of the walls of the cyst, and
of the abdominal walls. Palpation also enables us to detect the pres-
ence of peritoneal fluid between the tumor and abdominal wall, to
determine the density of the tumor, to detect smaller bodies in the
walls of a large cyst, and often to trace the outlines of several cysts by
the sulci which separate them. Semi-solid ovarian tumors are com-
moner than simple cysts; and solid tumors, although very rare, are
sometimes met with in the form of fibroma or cancer. On palpation,
PHYSICAL DIAGNOSIS.
85
their firmer texture and the absence of fluctuation serve to distinguish
them.
Palpation of Abdominal Aneurism.-Aneurisms of the aorta
are referred to, since those of other vessels rarely attain to much size.
They generally occur in men between twenty and forty years of age,
and are oftenest located between the aortic opening in the diaphragm
and the origin of the superior mesenteric artery; when below this
point the diagnosis is easier. When not too high up, they can easily
be felt, being from three to six inches in mean diameter, and often con-
taining as much as ten pounds. Owing to the liver and diaphragm,
they oftener develop downwards and to the left than upwards and to the
right. The tumor is smooth and elastic, and is most usually felt to
the left just above the navel. A deep inspiration does not depress it,
nor is it moved laterally by the fingers. A strong, single pulsation is
felt, synchronous with the radial pulse, and limited to the tumor.
Sometimes, also, a vibration or thrill is perceived by the fingers, which is
almost pathognomonic, when it exists. Pressure on the aorta below the
tumor increases the impulse, and diminishes the collapse and also the
thrill. A strong diagnostic point is the fact that the tumor expands
in every direction during the impulse, particularly at its sides, and does
not merely rise and fall like other tumors resting on an artery, such as
cancer of the stomach or of the left lobe of the liver. In such cases,
lifting the tumor from the artery or pushing it aside, or making the
patient assume the knee and elbow position, will sometimes stop the
pulsation. A functional aortic pulsation in the epigastrium is very often.
erroneously diagnosticated as aneurism. This may occur in dyspepsia,
hysteria, uterine or intestinal irritation or copious hæmorrhage. But here
the throbbing is not localized as in aneurism, but is propagated through
the aorta and into the main arteries below, and no tumor is found.
Percussion of the Abdomen.-The patient should be placed in
the same position for percussion of the abdomen as for palpation-
on the back, with relaxed abdominal muscles. Generally in marked
enlargement of the various organs this method is inferior to palpation;
but in such cases as free ascites, intestinal meteorism, accumulation of
gas in the peritoneal cavity, atrophies and dislocations of the liver, and
in the lesser forms of enlargement of the liver and spleen, it is de-
cidedly superior.
Percussion of the Liver.-A flat sound is heard over that por-
tion of the liver which comes directly in contact with the thoracic and
abdominal wall, from the fifth intercostal space on the right side in
front to the margin of the arch of the ribs below. This is the region.
of hepatic flatness as distinguished from that of hepatic dulness, so-
called, which extends above this line for an inch or so, where the liver
is overlapped by lung tissue, which adds some resonance. Forcible
percussion is in the latter place necessary to bring out the proper sound
86
A SYSTEM OF MEDICINE.
of the deep-lying organ; but near the lower margin of the right lobe,
and over the whole of the left lobe, on account of the thinness of both,
their superficiality and the proximity of the intestines and stomach,
light percussion is better adapted, in order to escape as much as pos-
sible the transmission of the tympanitic sound. The latter always
accompanies the dulness over the whole hepatic area in children, even
when the percussion is light. Owing to the movement of the liver
with respiration, it should be percussed during the respiratory pause,
and along at least four perpendicular lines, the axillary, mammary,
parasternal and median. Beginning in the mammary line, for in-
stance, above the right nipple, we notice the strong contrast of the
pulmonary resonance, the gradual transition at the overlapping, the
flatness of the body of the right lobe, the mixture of tympanitic
quality at the inferior margin, and the strong contrast of the intestinal
tympanitic sound below. In this way on the different lines we map out
the upper and lower margins of the liver with great accuracy. In the
mammary line the liver measures about four inches; hepatic dulness
begins at the fourth intercostal space, hepatic flatness at the fifth, and
the lower border of the organ is reached at the edge of the arch of the
ribs, seldom in health passing below. In the median line it measures
about three inches; flatness is reached at the base of the xiphoid pro-
cess, and the lower border is found nearly halfway between this point.
and the umbilicus. In the parasternal line the boundaries are between
those of the two latter. In the axillary line the liver measures about
four and a half inches; dulness is reached at the seventh rib, and
flatness at the eighth. In the scapular line the lower dulness is at the
eleventh rib. Near the vertebral column the upper boundary is near
the tenth rib, but the lower boundary cannot be accurately deter-
mined, as the dulness here is continuous with that of the right kidney.
The dulness of the left lobe, which reaches nearly two inches across
the median line, also merges so closely into that of the heart that they
cannot be distinguished; which fact, however, is not of much practical
importance. The liver may be dislocated by tight lacing. When it is
dislocated downwards by emphysema or pneumothorax, percussion
very readily traces its upper border and corrects the impression of
its enlargement which palpation might give. If the dislocation is
caused by right-sided pleuritic exudation, however, this method
fails, as one dulness runs into the other. Dislocation upwards by
pressure from below by abdominal tumors, meteorism, ascites, etc.,
very rarely exceeds one intercostal space. When the liver is enlarged
too little to be recognized by palpation, the increase will give on per-
cussion a dull, tympanitic sound. Even if the liver is decidedly en-
larged, percussion may fail to outline it if there be a great amount of
ascites or meteorism. In the first place, the two dull sounds are con-
tinuous; and in the second, the gas-distended colon may come between
PHYSICAL DIAGNOSIS.
87
the liver and the abdominal wall and produce a tympanitic sound;
an air-distended stomach may also mask an enlarged left lobe. Care
must be taken not to mark as signs of enlarged hepatic area fæcal
masses in the transverse colon or tumors of the pylorus. Palpation
or the rational symptoms may solve the problem. By waiting until
another hour or day, changes will take place in the location of fæcal
matter, in the amount of food in the stomach, in the overlapping of
the liver by coils of intestine, etc., which will clear up some difficulties
in percussion. The area of hepatic dulness is diminished, as just
stated, by the overlapping of coils of intestine, by the encroachment
of an emphysematous lung covering the upper part of the liver, and
by its crowding upwards by abdominal distension, its upper part being
pushed more behind the lung. If these causes are absent, diminution
of its area of dulness may be set down as indicating contraction, espe-
cially from cirrhosis or acute yellow atrophy. With the former ascites
often coexists, and its withdrawal is first necessary, or else the patient
when percussed must lie on the left side to allow the fluid to gravitate
that way. In acute yellow atrophy the liver may shrivel up and sink
back so much that its dulness may entirely disappear.
Percussion of the Spleen.-The spleen is only about four inches
long and three wide, and runs parallel to and behind the ninth, tenth,
and eleventh ribs, its upper end being close to the body of the tenth
dorsal vertebra, and its lower end coming about to the middle axillary
line. Being small and thin, and almost surrounded by air-containing
organs, its sound is not nearly so dull as that of the liver; in chil-
dren, as a rule, and sometimes even in adults, the tympanitic sound
which prevails in its neighborhood being only slightly muffled over it.
The percussion-stroke must, therefore, be gentle. The upper third
of the spleen can never be recognized by percussion, being entirely
covered by lung; and with a full inspiration so much of the lung
comes down as sometimes even to cause the complete disappearance
of the splenic dulness. Percussion should, therefore, be performed in
the respiratory pause. A dilated stomach or a gas-distended colon
will also encroach on the splenic dulness, and make it difficult to de-
tect. The patient may either stand, sit, or lie on the right side, but
the area of dulness will shift a little with the position of the patient.
To outline the spleen, we percuss in a line from the axilla to the crest
of the ilium. The upper limit of dulness is usually found at the ninth
rib and the lower limit at the eleventh. On a horizontal line between
these two we percuss from the median line to the left to find its ante-
rior edge, which is near the middle axillary line. It is of little use to
percuss behind, as the splenic dulness is continuous with that of the
kidney. It is also difficult to distinguish the spleen when there is a
left pleuritic effusion. If large, however, it brings it within the reach
of palpation. In pulmonary emphysema, owing to the overlapping
88
A SYSTEM OF MEDICINE.
of the lung, the area of dulness is greatly reduced or disappears.
When the spleen is enlarged, its normal oval or rhomboidal outline is
preserved. If moderate in amount, dulness extends downwards and
backwards; if still greater, it also extends forwards, and when it is
immense, it also pushes the diaphragm before it up into the thoracic
cavity. The dulness of an enlarged spleen is always more intense,
owing to the greater thickness of the organ. It is, therefore, far more
easily recognized by percussion than a normal spleen, except when
there is much meteorism or ascites present. After all, although per-
cussion is confirmatory of a large splenic tumor, palpation affords
much more trustworthy evidence.
Percussion of the Stomach.-Not all of the stomach can be
traced by percussion, for the upper part to the right is covered by the
liver, and to the left by the lung. The rest touches the wall of the
abdomen. Its larger curvature crosses the epigastrium in a curved
line about half-way between the point of the xiphoid process and the
umbilicus, when moderately distended, and its left edge reaches a
very little beyond the right edge of the spleen. The patient should.
lie on his back. The upper border of the superficial gastric area is
found by percussing downwards from the overlapping lung, and
noticing where the pulmonary resonance stops and the tympanitic.
begins, which is generally below the sixth rib. From the liver the
transition is, of course, very abrupt; but the colon on the lower boun-
dary sometimes sounds so nearly like the stomach, that it is almost
impossible to define their boundaries. It generally, however, has a
higher pitch, and is more purely tympanitic, the difference being
noticeable to a practiced ear. Where it is hard to distinguish the two
sounds, the patient may be requested to swallow a glass of water, and
to stand up during percussion. The lower boundary of the stomach
will then be indicated by a dull sound.
The sound of the stomach varies according as it is empty, partly
filled, or fully distended by its contents. If empty, it gives out a
clear tympanitic note of low pitch; if quite full of solids and fluids,
the tympanitic element is more or less muffled, especially at the lower
parts of the great curvature; if only moderately full, it is hollow,
ringing, and tympanitic to a certain extent, yet not so much so as the
intestine; and sometimes it is amphoric. If the stomach is greatly
overloaded with food, the tympanitic area is extended in different
directions, not only downwards but also to either side, masking some
of the hepatic and splenic dulness. If greatly distended with gas,
the percussion note is metallic as well as tympanitic. Artificial dis-
tension with gas is sometimes resorted to in order to mark out more
clearly the outlines of the stomach. A solution of bicarbonate of soda
is swallowed soon after a solution of tartaric acid.
The stomach may be dislocated downwards by a large pleuritic
PHYSICAL DIAGNOSIS.
80'
effusion or by emphysema, and upwards by ascites or large abdominal
tumors. Its resonant area may be diminished by large tumors of the
liver or spleen; and increased by pathological dilatation, such as may
'occur with stricture of the pylorus, or in old gastric catarrh. In the
latter cases, the gastric tympanitic sound may extend as far down as
the umbilicus, beyond the median line to the right, and beyond the
axillary line to the left.
Percussion of the Intestines.-In health the percussion sound
of the intestines, both great and small, is always tympanitic. In
intensity and pitch it varies greatly with the constantly varying gas-
eous, liquid and solid matters they contain; but although a greater
proportion of solids and a less of gases will partially deaden the sound,
yet it never becomes absolutely dull, no matter how large the fæcal
accumulation. The descending colon, especially in the left iliac region,
is the part most apt to be filled with excreta. The tympanitic sound
of the large intestines is lower in pitch, as a rule, than that of the
small. The sound is best developed when the abdominal muscles are
relaxed. When there is a very large accumulation of gas in the in-
testines, with great tension, the percussion sound is lower in pitch,
but less truly tympanitic. The same quality of sound is heard when
the accumulation of gas takes place in the peritoneal sac (generally
from perforation of the intestines). Although the latter condition, on
account of the violence of its symptoms, is not apt to be confounded
with the former, yet there is this difference in physical signs: the gas,
being unrestrained, bubbles up between the liver and the abdominal
surface, so as to cause the disappearance of the hepatic dulness on
both sides of the median line, which is not the case in meteorism.
Percussion of Ascites.-If the whole abdomen is filled with
fluid, the percussion sound is everywhere dull; unless, as frequently
happens, coils of intestine float upon the surface of the fluid, when
the sound will be, in such places, clear tympanitic on gentle percus-
sion, but dull tympanitic on forcible percussion with firm pressure.
If the fluid is only sufficient to fill the pelvic cavity, it cannot be
detected by percussion. A very important point to be remembered
in connection with the recognition of ascitic fluid is the change of
percussion sound with the change of position. Obeying the laws of
gravity, the fluid seeks the lowest parts. If the patient stand, it
settles to the inferior part of the abdomen. If he lie on his right side,
it settles to the right; if on his left side, it settles to the left. In what-
ever direction it sinks, we find dulness, and, at the same time, a clear
tympanitic sound in the uppermost parts; so that in one position the
right side is dull and the left tympanitic, and, on turning over, the
left side is dull and the right tympanitic. A very slight accumulation
of fluid, too little to give rise to fluctuation, may be detected in this
way, by a slight change in the resonance of the flanks on change of
9.0
A SYSTEM OF MEDICINE.
position. Even if there is such an excess of fluid that the whole of
it cannot leave one side for the other on change of position, yet the
dulness at the upper part is rendered less intense, although it may
not become clear. The extreme dulness found in the lower part of·
the abdomen when the patient stands, clears up considerably when
he lies on his back, owing to the equalization of the fluid. It will
readily be seen that by percussion we have a tolerably accurate method
of determining the level of the effusion. Ascites may often be com-
plicated by oedema of the abdominal walls, when percussion becomes
more difficult. The change in percussion sound on change of position
is generally sufficient to distinguish ascites from ovarian dropsy.
Sometimes these two conditions coexist, when, unless the tumor is
very large, both can be detected; the ascites by percussing in different
positions, and the tumor by palpation. If the peritoneal effusion is
encysted, there will be no change in percussion sound on change of
posture.
Percussion of the Kidneys.-It is impossible to mark out the
outlines of the kidneys by percussion, on account of the non-resonant
textures which almost surround them. The liver above the right
kidney, the spleen above the left, the transverse processes of the ver-
tebræ between, and the coverings of their fatty capsules and the thick
layer of back muscles, produce an indistinguishable and continuous
dulness. The only places where a contrast can be found are the lower
halves of their external convex borders and their lower ends; and
near them the tympanitic sound of the colon comes out with more or
less distinctness, especially when the patient lies on his abdomen,
allowing any fluid to sink away and the intestines to rise. For these
reasons, in practice percussion is of little avail, and is almost never
resorted to except in cases of floating kidney, and large tumors, such
as hydronephrosis. In the former, where a kidney has left its moor-
ings, the absolutely dull sound is sometimes, but not always, replaced
by a dull tympanitic sound. In the latter the area of dulness is quite
extended.
Percussion of the Bladder.-When empty, the bladder is not
recognizable by percussion; but when tensely distended, it gives forth
a very decided dull sound in the hypogastric region, which does not
change with change of position, but which entirely disappears after
the introduction of the catheter. It very rarely happens that a coil
of intestine, getting between the bladder and the abdominal wall, adds
a tympanitic quality to the dulness.
Percussion of the Uterus.-Like the bladder, the uterus is
recognized by percussion only after it leaves the pelvis. Then,
whether enlarged by pregnancy or by pathological causes, it is abso-
lutely dull in all places, unless, as very rarely happens, a coil of in-
testine, getting over it, adds a tympanitic sound to the dulness. In
PHYSICAL DIAGNOSIS.
91
the flanks the intestinal tympanitic note is heard, which still remains
as a contrast in different positions of the patient.
Percussion of Ovarian Tumor.-This resembles closely the
percussion of the pregnant uterus. Dulness is found, or, more strictly,
perfect flatness, over the whole growth, while the intestinal tympanitic
resonance is heard generally in the flanks.
Auscultation of the Abdomen is of very little practical advan-
tage, except to determine the life or death of the foetus in cases of
pregnancy. Outside of this, the sounds heard have reference mostly
to the gastro-intestinal canal, and although they add little to our
information about diseases of this tract derived from other sources,
yet it is well to be acquainted with them in order to avoid mistaking
them, as beginners frequently do, for physical signs produced within
the lungs or heart.
Auscultation of the Stomach and Intestines.-If repeated
and quick pressure is made on the abdomen, a loud, ringing metallic
splashing or gurgling sound is sometimes heard, even at a distance
from the patient. This is caused by the agitation of the contained fluid
and air, and resembles the Hippocratic succussion sound, or the shak-
ing of a bottle half full of water. Such noises may also sometimes
originate spontaneously, without pressure, but are more feeble. In
diarrhoea or cholera they may be heard over the whole of the abdo-
men, and in typhoid fever in the ileo-cæcal region. Either pressure
or the peristaltic action may cause them, or the contraction of the
abdominal muscles. Borborygmi are rumbling noises caused by the
rapid passage of gas through the intestines, forced by their peristaltic
action. Everyone is familiar with them, often coming when the
stomach and bowel are empty, in diarrhoea, or in simple flatulence.
All of these sounds have been mistaken for lung or heart signs, but
are distinguished by their irregularity, by their having no connection
with inspiration or expiration, or with the systole or diastole, and by
their continuance even when respiration is suspended. When the
bowel is perforated, murmurs of a blowing amphoric character may
be developed, but the accompanying violent symptoms will readily
point to their cause.
Auscultation of the Pregnant Uterus.-If with the stetho-
scope we listen over the uterus during and after the fifth month of
pregnancy, the most important and positive of all the signs of that
condition-the fatal pulsation-is heard. A murmur called the
uterine souffle is also heard, even earlier than the foetal pulsation.
Still another sound some have professed to hear-the funic souffle-
produced in the umbilical cord; but it is so very uncertain, and also
so unimportant, even if heard, that no further mention of it will here
be made.
Foetal Pulsation.-Strange as it may appear, the sounds of the
92
A SYSTEM OF MEDICINE.
heart of the fœtus in utero have been heard only for the last sixty or
seventy years. They are double, naturally very small and weak,
resemble the ticking of a watch wrapped in a napkin, vary in fre-
quency, but range from 120 to 160. The movements of the fœtus
increase their rapidity, but the mother's pulse does not affect them.
They can only be mistaken for the latter when the mother is feverish
or excited; and even then the finger on the mother's wrist, or the
increased intensity of the beats as the mother's heart is approached
with the stethoscope, will solve the problem. The foetal pulsations are
often hard to find, being heard only over a limited area, which varies
with the position and presentation of the child. Its back transmits them
best, and, therefore, they are best heard at that part of the mother's
abdomen which corresponds to it. The frequent change of the posi-
tion of the fœtus before the seventh month thus explains the frequent
change of position of the foetal pulsation before that time. During
the last three months the child generally lies with the head downwards
and the back forwards and to the left, the back thus coming in contact
with the parietes a little to the left of the median line. This then is
the place of election, so to speak, there being here continuity of tissue.
Elsewhere the amniotic fluid cuts off the sound. In the second
cranial position the sound will be heard at the right of the median
line. In either case it is about half-way between the umbilicus and
the symphysis pubis. In the common breech presentations it is
heard as high as, or higher than, the umbilicus. Some positions, like
the dorso-posterior, or a large amount of amniotic fluid, increase the
difficulty; but as a rule, in any position, if the foetal heart is not
heard somewhere after the fifth month, it goes far to prove that there
is no pregnancy, or that the fœtus is dead. It has been claimed that
the sex of the fœtus in utero can be told by the frequency of the beats,
being male if below 130 or 135, and female if above. Without doubt,
in a considerable majority of cases the male pulsations are less fre-
quent than the female, and this method may be of assistance to us;
but like all instances when an "average" number enters into a com-
putation, the particular case in hand may be an exception to the rule,
or in the minority, and, therefore, too confident a prediction must not
be made. When twins lie in the womb, one on the right and one on
the left, as they usually do, two pulsations may be heard, which, if
not synchronous, will establish the dual pregnancy. Where the pul-
sations of a single foetus are heard in two places, it is said that the
maximum of intensity lies between them, which is not the case with
twins. These points, however, are much easier to discuss than to put
into practice.
The Uterine Souffle.-As to the mode of production of this
murmur (called also, among other names, the placental souffle), there
are many theories which need not here concern us. It is maternal,
PHYSICAL DIAGNOSIS.
93
not foetal, being coincident with the mother's heart beat, and is heard
after the sixteenth week, when the uterus is accessible to the stetho-
scope. It is not always constant, sometimes disappearing to return
again in a short time, and is heard all over the abdomen, or limited
to a small place, usually in the groin; in advanced pregnancy over
the lower part of the uterus only, as a rule. It varies greatly in
quality and pitch, resembling all kinds of cardiac murmurs. During
a labor pain the sound first becomes louder, even musical, and then
disappears at the height of the pain, reappearing in the same order
inverted as the pain passes off. Its location affords no evidence of the
situation of the placenta. Unlike most arterial sounds, it persists in
every posture and has no impulse with it. Being heard also some-
times in connection with pathological uterine tumors, it must not be
taken as a certain sign of pregnancy.
Auscultation of Abdominal Aneurism.-When the patient is
lying down, a bellows murmur is almost always heard in front over
the aneurism, and is almost invariably single, blowing (though some-
times musical), prolonged, post-systolic, and not transmitted into the
vessel beyond. If the patient stands erect, the murmur is usually
suspended. A sound without a murmur, usually double, is generally
heard behind (rarely in front), at a point corresponding to the tumor.
A murmur, resembling that of aneurism, may sometimes be produced
by pressure with the stethoscope on the abdominal aorta, but this dis-
appears when the pressure ceases. A non-aneurismal tumor may also
by its pressure produce a murmur, but this will disappear when the
hand and knee position is assumed, the weight of the tumor being
thus removed.
PHYSICAL EXAMINATION OF THE URINE.
It would be out of place to attempt to give here anything like a full
exposition of the methods and results of the physical, chemical and
microscopical examination of the urine. Only such parts of it will be
selected as have the most important bearing on the physical diagnosis
of disease. In any case where the symptoms furnish the least suspi-
cion of renal disease, the urine must be examined as a matter of
course. Moreover, owing to the insidiousness of the approach of such
troubles, and their frequent connection with other diseases which,
having more marked symptoms, often mask their own, its examina-
tion is frequently called for, as a precautionary measure, when no
kidney trouble is suspected, and the examiner is often rewarded for
his care by a flood of light in a doubtful case. In such examinations,
our inquiries should be particularly directed to the quantity of the
urine, its color, reaction, specific gravity, the amount of its urea, urates,
94
A SYSTEM OF MEDICINE.
phosphates and chlorides, and the presence of abnormal constituents,
such as albumen, sugar, pus, blood, etc.
The quantity of urine passed in twenty-four hours varies in health
between thirty and sixty ounces, or even more, according to the amount
of fluid drank, the perspiration, etc., perhaps averaging about fifty
ounces. When accuracy is required, the whole amount passed in
twenty-four hours should be collected, measured and averaged for two
or three successive days, as transient variations will usually equalize
themselves in that time. Anything that raises the arterial tension,
like cold or nervous excitement, will increase the flow. More is passed
when one is awake than when asleep, and the very fact that one has
to rise during sleep excites a suspicion of disease. It is not always
safe to trust the statements of patients as to the quantity passed, and
frequent micturition, being so much a matter of habit, cannot be taken.
as an index. The urine is persistently increased in diabetes mellitus
and diabetes insipidus to three, four, or even eight times its proper
bulk, and also somewhat in waxy and granular kidney. In the first
there is sugar, in the second neither sugar nor albumen, in waxy kid-
ney much albumen, and in granular kidney little albumen. Hysteri-
cal fits often end with a great flow of urine. The urine is diminished
in all febrile affections, even when the patient is drinking freely and
not sweating excessively; in the stage of failure of compensation in
diseases of the heart, with low tension in the arteries and full veins;
in acute nephritis; in granular kidney shortly before death; and in
some nervous disorders.
In color normal urine varies from a very pale, almost imperceptible
yellow to an amber or yellowish-red, according to the amount of pig-
ment or the degree of concentration. In febrile diseases or in chronic
affections, when the volume of urine is greatly diminished, the color
becomes red or reddish-yellow. It is pale in granular kidney, anæmia,
chlorosis, diabetes mellitus and insipidus, and after a fit of hysteria or
asthma. The presence of bile gives to the urine various shades of
brown or green. It may be detected by dropping a little impure nitric
acid (containing nitrous acid) on some of the urine poured over a
white plate, or soaked into a piece of white blotting paper; a series of
beautiful rings of green, blue and violet will be formed when the two
fluids meet. Blood in urine in small quantity gives it a smoky look,
and in greater amount a blood-red or coffee color. If long diffused in
it, it may give it even an inky blackness. The corpuscles can be
recognized by the microscope. The constant use of carbolic acid or
creasote may make the urine black. In melanotic cancer the urine,
although of natural color when passed, may turn brown or black after
long contact with the air, or on the addition of nitric acid.
In reaction fresh normal urine is generally acid, turning blue litmus
paper red, but not affecting red litmus paper. After exposure to the
PHYSICAL DIAGNOSIS.
95
air for some time it becomes alkaline, owing to the decomposition of
its urea and its conversion into carbonate of ammonia. Such urine
has a strong ammoniacal smell, colors red litmus paper blue, and gives
a white vapor of chloride of ammonium when a glass rod dipped in
hydrochloric acid is held over it. The acidity of fresh urine is di-
minished by vegetable diet and by alkalies, but increased by a flesh or
milk diet, by acids, by muscular exercise, by diabetes, and by febrile.
diseases, especially rheumatic fever. The urine is often alkaline in
diseases of the stomach, in pyelitis or cystitis (when it is loaded with
pus), and when it is inoculated inside the bladder by a dirty catheter.
Urine which is alkaline when passed is always turbid from precipita-
tion of the phosphates.
it
The specific gravity is most easily taken by means of the urinome-
ter, and varies in health from 1015 to 1025, distilled water being 1000.
If there is not enough urine to take the specific gravity in the usual way,
may be diluted with one, two or more volumes of water and the
urinometer then used, the decimal figures thus found being multiplied
by the number of times the urine has been diluted. The specific
gravity, depending on the amount of solids excreted, to be of value,
must necessarily be considered in connection with the quantity of
urine passed. It is diminished by any cause which increases the flow
of water, such as copious draughts, diuretics, etc.; and is increased by
profuse perspiration, by long retention in the bladder, etc. These
changes usually balance themselves in the twenty-four hours, and the
whole amount passed in that time may be collected, mixed and tested.
This, however, is not generally necessary. The fairest sample is that
passed just before breakfast.
The specific gravity of the urine is somewhat increased in febrile
diseases, owing chiefly to increased excretion of urea, and diminution
of water. It here rarely exceeds 1030. It is also increased by the
presence of albumen or blood, if the urea is normal in amount. The
reason why albuminous urine is generally of low specific gravity is
that with albuminuria the urea is often greatly deficient. If the den-
sity ranges persistently from 1030 to 1040, or 1050, or even higher,
although the quantity of urine is increased, diabetes mellitus is indi-
cated, and the sugar can be detected by chemical examination. In
diabetes insipidus the density is naturally diminished, and it is often
low in anæmia and hysteria. In contracted or amyloid kidney the
specific gravity may fall to 1005. The most important solids of the
urine are inorganic salts (the principal of which is common salt) and
urea, the quantitative estimation of the latter being of the greatest im-
portance, in view of the seriousness of its retention in the blood and
causing uræmia. A rough estimate of the amount of solids in the
urine can be obtained by multiplying the last two figures of the specific
96
A SYSTEM OF MEDICINE.
gravity by 2. This will give the number of grains of solid matter to
1000 grains of urine.
The amount of urea in healthy urine varies considerably, but aver-
ages about 500 grains a day. It represents the waste product of the
nitrogenous elements of the body and of the nitrogenous food taken
into it, and is therefore increased by very active exercise and by ani-
mal diet. An exact quantitative analysis is not necessary for clinical
purposes. Its amount may be roughly estimated by the addition of
strong nitric acid to an equal amount of urine in a test-tube which is
placed in cold water. If the urea is in excess, crystals of nitrate of urea
readily make their appearance, but do not form in normal urine until
it is concentrated by heat. The amount of concentration necessary to
their formation therefore becomes a measure of the deficiency of urea.
By a simple expedient, the crystals may be seen to form themselves
under the microscope. One end of a thread being in a drop of urine.
on the slide and covered by a thin covering-glass, the other end is wet
with nitric acid. If the urea is in excess, the hexagonal plates of its
nitrate soon show themselves. Practically, however, the commonest
and perhaps the easiest way to estimate the quantity of urea in the
urine of persons for whom we fear uræmic poisoning, is to take the
specific gravity of such urine, at the same time bearing in mind its
quantity. A low specific gravity with a small quantity of urine indi-
cates a deficiency of urea; but a low specific gravity, if the urine is
more plentiful, or a high specific gravity with a small quantity of
urine, need give us no apprehensions of uræmia. The specific gravity
alone, therefore, is no guide; it must always be interpreted in the light
of the quantity of the urine.
The urates are deposited as a sediment only after the urine has
cooled, as they are soluble in water at the temperature of the body.
Unlike the phosphates, therefore, they are redissolved when warmed,
the muddy look clearing up. Their color is usually that of brick dust,
although it may vary from white to red. When their bases are de-
ficient, or the acid is in excess, the red, pepper-like particles of uric
acid may be deposited. Although the deep and positive color of the
incrustation of uric acid and the urates on the chamber vessel is apt
to alarm many persons, yet they may not be connected with any dis-
turbance of health whatever, coming on frequently after violent exer-
cise or perspiration. They may result from errors in eating and
drinking, or indicate local irritation of the kidneys or bladder. They
are found in excess in heart and lung diseases, when oxidation of the
blood is deficient, in organic diseases of the liver, in most febrile dis-
eases, and sometimes in diabetes, chorea and certain skin diseases.
They are deficient or absent in advanced kidney diseases, in lead
poisoning, in general anæmia, in some exhausting non-febrile diseases,
and in chronic gout. In acute gout they are at first diminished, but
PHYSICAL DIAGNOSIS.
97
reappear when the attack passes off. The liability to the formation of
calculi must be remembered.
The phosphates of lime and triple phosphate are deposited when
the urine becomes alkaline, and are readily redissolved by the addition
of acid, but not by heat. They may cause turbidity in the fresh urine.
of persons working their brains unduly at the expense of their bodies,
not on account of their excess, but because of the diminished acidity of
the urine. They are deposited in acute and chronic brain troubles and
towards the close of pleurisy, pneumonia and rheumatic fever. If the
cause of the alkalinity of the urine which continually or frequently
deposits them is soda or potash, a grave disorder is indicated, marked
by debility, anæmia, and nervous dyspepsia, and representing an
altered condition of blood and nutrition. If the carbonate of ammonia
is the cause, lowered vitality from age, spinal injury or disease is in-
dicated. Provided there be a nucleus for them to form on in the
bladder, they readily and rapidly grow into calculi, sometimes of
enormous size. Whenever the freshly voided urine contains them for
a long period, calculi are to be feared.
The chlorides in the urine depend principally on the amount of salt
eaten. In all acute febrile diseases, especially if accompanied by an
exudation, as pneumonia, acute articular rheumatism, pleuritis, peri-
carditis, etc., the chlorides are diminished to a remarkable degree, or
even are completely suppressed. In such cases their reappearance
and steady increase indicates an amelioration of the disease. The
usual test for the chlorides is the striking and beautiful precipitate by
the nitrate of silver solution.
Albumen (sometimes spelled -min) is by far the most important of
the abnormal constituents of the urine. Its presence in greater or less
quantities is to be determined by the conjoined nitric acid and heat
tests, which can be found fully explained in so many books, that their
repetition here is not necessary. The student should keep constantly
in mind, however, the fallacies incident to the employment of either
test alone, and should invariably correct one by the other. Many
more tests have been devised, some of which are more delicate, but
these are the most common and convenient, and are very satisfactory.
For some time after Bright made his famous discovery, the whole
profession regarded albuminuria as synonymous with Bright's disease;
and even now the number of physicians who prognosticate life or death
solely from the action of the contents of a test-tube with heat and
nitric acid is surprisingly large. It is exceedingly important to have
correct ideas on this subject. The fact ought to be strongly impressed
on us that any considerable and persistent amount of albumen in the
urine indicates either primary or secondary kidney trouble, and gives
good cause for anxiety; and yet if we should condemn to death every
patient whose urine is albuminous, we should commit the most egre-
gious blunders. Not only may albuminuria exist without renal dis-
VOL. I.-7
98
A SYSTEM OF MEDICINE.
ease, but also even renal disease may exist (though rarely) without
albuminuria. In one of the worst forms of all, the contracted or
granular kidney, albumen is only fitfully present, and is often absent
for long intervals.
If the urine contains pus or blood, it will be slightly albuminous.
If a healthy person eat moderately of eggs or other largely albumi-
nous articles of food, they will probably be perfectly digested; but if
more be eaten than can be thoroughly assimilated, especially if this is
the exclusive diet, albumen may temporarily appear in the urine. After
very violent exercise or excitement (as with Weston after his famous
long walk), a little albumen may appear in the urine of apparently
healthy persons; but this will occur in a tolerably small proportion of
cases. Albumen, however, is not properly a constituent of healthy
urine even in small quantities, and some who have showed this symp-
tom in apparent health, have afterwards succumbed to kidney disease.
One of the best authorities, William Roberts, says that: "The patho-
logical states in which albumen appears constantly or occasionally in
the urine may be arranged in the following group: 1. Acute and
chronic Bright's disease of the kidneys. 2. Pregnancy and the puer-
peral state. 3. Febrile and inflammatory diseases. (Zymotic diseases,
such as scarlet fever, measles, small-pox, typhoid, cholera, yellow fever,
ague, diphtheria, etc.; inflammatory diseases, such as pneumonia,
peritonitis, traumatic fever, acute articular rheumatism, etc.). 4. Im-
pediments to the circulation of the blood, causing venous congestion
of the renal veins (as in emphysema, heart disease, abdominal tumors,
cirrhosis, etc.). 5. A hydræmic or dissolved state of the blood and
atony of the tissues (purpura, scurvy, pyæmia, hospital gangrene);
also hæmaturia. 6. Saturnine intoxication. 7. Neurotic albuminuria
(nervous disturbance)."
Thus it is seen that a great variety of conditions of the system may
produce albuminuria. If, however, the albumen is persistent, if it is found
in large quantities (one-half of the test-tube and upwards, almost invari-
ably indicating acute or chronic nephritis), if it is associated with other
symptoms of kidney disease, and if other diseases which might cause it are
absent, the conclusion of Bright's disease is irresistible.
Sugar in the urine (as well as albumen) generally frightens the
physician, and well it may in most cases. Still, it should be remem-
bered that while it often heralds disaster, it does not always indicate the
classical diabetes, so-called, which is so notoriously fatal. For it may
sometimes (though not often) occur in the merest trace in apparently
perfect health, especially if more sugar or starch is eaten than can be
properly assimilated. It may sometimes also occur after the adminis-
tration of chloroform, after paroxysms of whooping-cough, asthma or
epilepsy, in recovery from cholera, in measles, pneumonia, erysipelas,
and in some brain and spinal troubles. Thus, we see that glycosuria
is not always diabetes. Further, diabetes is not invariably (although
PHYSICAL DIAGNOSIS.
99
it is too often) the hopeless disease with persistent and intense gly-
cosuria, and greatly increased flow of urine, with thirst, debility, ema-
ciation, etc. "There are," Roberts says, "less serious types in which
sugar is present in the urine, sometimes abundantly, sometimes scan-
tily, sometimes persistently, sometimes intermittently, always with a
weakly condition of health, but without thirst or conspicuous emacia-
tion, often indeed with corpulence; without any or only slight increase
in the quantity of urine, and without that fixed tendency to death,
which stamps the other cases; occurring also generally in advanced
years, or at least beyond the time of early manhood."
Diabetic urine, as already stated, has a high specific gravity, not-
withstanding that it is generally passed in great quantity; it quickly
ferments, develops torulæ, and rotates the plane of polarization to the
right. Of the many tests for detecting sugar, the best is that of Trom-
mer, with sulphate of copper and liquor potassæ, which is in constant
use among physicians.
Blood in the urine can usually be recognized by the naked eye, by
its smoky, pink, red, brown or black color, and its globules can be seen
under the microscope. It may be furnished in greatly varying quan-
tities by any part of the urinary tract from the kidney downwards,
and looks more natural the lower down its origin. When it comes
from the urethra from local inflammation or rupture of vessels, it is
not apt to be passed directly with the urine, or is not intimately mixed
with it, and comes pure in somewhat large quantities. When it comes
from the bladder, also, from inflammation, ulceration, malignant dis-
ease or stone, or fevers of a low type, it is not very intimately mixed,
if in large quantities, being mostly in clots, and soon separates on
standing; or it does not pass until near the end of micturition. When
it comes from the ureters, as, for instance, from calculi, long, thread-
like coagula are passed, looking something like lumbricoid worms, and
causing colic during their passage through the ureters. These casts
may also be formed in the ureters from a copious renal hæmorrhage.
When it comes from the kidneys, and does not thus coagulate, it is
intimately mixed with the urine, and does not very readily precipi-
tate; after awhile, however, more or less of a coffee-ground sediment
appearing. When coming from the kidney, it may indicate either in-
jury from a blow or strain, congestion, inflammation, cancer, calculi,
hydatid disease, nephritic colic or pyelitis. Blood-casts of the urini-
ferous tubes are frequently seen under the microscope. Hæmorrhage.
from the kidney is particularly characteristic of the advanced stage of
the contracted or cirrhotic kidney. It may also come from large doses
of turpentine and cantharides, from purpura hæmorrhagica, scurvy
and small-pox, scarlet fever, and other eruptive or continued fevers.
When there is blood in the urine, its albumen can be recognized by
the usual tests. Sometimes the coloring matter alone (hæmatin,
hæmaglobin) is found (and may be detected by the spectroscope or
Uor M
100
A SYSTEM OF MEDICINE.
guaiacum test), the corpuscles having undergone disintegration, as in
paroxysmal hæmatinuria.
Mucus in healthy urine exists in mere traces, and imparts a slight
cloudiness after standing for awhile. It is derived mostly from the
urethra, and in women also from the vagina, and often contains epi-
thelium. In catarrh of the bladder it is found in abundance as a viscid
stringy cloud, floating about for a long time, and finally settling to the
bottom. This rapidly promotes the decomposition of urea, and the
urine consequently becoming ammoniacal, deposits phosphates, and
still further irritates the mucous membrane. Other parts of the uro-
poëtic system, even up to the kidney, may be involved, as well as the
bladder, in a local trouble, or the increased quantity of mucus may be
due to typhus, pneumonia, etc.
Pus in the urine makes it turbid, and after awhile settles as a whitish
deposit. If the urine is not ammoniacal enough to destroy them, the
pus-corpuscles may be seen with the microscope. Ammoniacal urine,
or that to which an alkali has been added, makes the purulent deposit
gelatinous or stringy. Pus in urine always causes it to be somewhat
albuminous. If the pus can be squeezed out of the urethra without
urination, it comes from the urethral canal. If it comes from the in-
flamed bladder, or vagina, or prostate gland, or ureters, there are gen-
erally other symptoms enough to indicate its source. In most cases,
when it comes from the kidney, the disease is pyelitis resulting from
renal calculi, and is accompanied by attacks of colic. It may some-
times come from abscess of the kidney, and then appears in the urine
suddenly.
Casts of the uriniferous tubes are exceedingly important from a di-
agnostic point of view. They are to be sought for with a microscope
magnifying about 300 diameters or less, in the sediment or in the
lower layers of a considerable quantity of urine, which has been allowed
to stand for some hours. Several examinations should be made before
concluding that they are absent. A few years ago, even after the mod-
ification of the common views at first entertained as to the universally
dangerous import of albuminuria, casts were considered as invariably
the precursors of death. Although, in the light of further experience,
such extreme views are not tenable, yet it must be admitted that in the
great majority of cases in which they are apt to be looked for, they
indicate a very serious and possibly, if not probably, fatal disease.
When they are found, before we are too confident as to their signi-
ficance, frequent examinations at intervals should be made. They not
only give us valuable information as to the existence of kidney dis-
ease, but also as to its kind and stage. Where two or more varieties
of casts are seen in the same specimen of urine, as is frequently the
case, the determination of their significance is facilitated by noticing
carefully which variety preponderates. No one variety indicates ex-
clusively any particular disease. The number of casts is not always
Maou
PHYSICAL DIAGNOSIS.
101
to be relied on as an index. In chronic nephritis, to be sure, they are
apt to be proportionate to the severity and stage of the disease; but in
granular kidney they may be very few, and, on the other hand, in the
convalescence from acute nephritis they may be quite numerous.
The most common varieties of casts are epithelial, granular, hyaline
or waxy, fatty, bloody and purulent. Epithelial casts are found more
particularly in the early stage of acute desquamative nephritis. Granu-
lar casts differ much in their nature and significance. They oftenest
indicate chronic nephritis, the granulations coming from disintegrated
epithelium. In granular or contracted kidney they are large, dark
and coarse. When coexisting with blood-casts, with broken-down
corpuscles, or with fatty casts resulting from the degeneration of in-
flammatory products, they may indicate approaching recovery from
acute nephritis. Hyaline casts, which, on account of their transparency;
sometimes escape detection, are found more frequently than the other
varieties, and may occur in all forms of Bright's disease, acute as well
as chronic, but particularly in the amyloid or waxy kidney. Cutting
off a part of the light from the object-glass, or staining with carmine
will render them more visible. When of an inch in diameter, they
are called large, and when 。, small. The large mean more mischief
than the small, being formed in tubules denuded of their epithelium,
or dilated by intertubular contraction, and, as a rule, chiefly occur in
chronic nephritis. Very exceptionally they are found in acute cases.
Small hyaline casts occur in both the acute and chronic forms, and
therefore their interpretation should be in the light of the history of
the case, etc. They are sometimes found in cases of simple congestion
of the kidney, and in diabetes, jaundice, and diphtheria. Fatty casts,
studded with oil-globules, must be interpreted with much caution in
the light of other facts, occurring, as they do, in such various condi-
tions. If abundant and full of oil-drops, they denote fatty degenera-
tion, and are, of course, of the gravest import; but they may also be
found in the later stages of acute nephritis during convalescence.
Hyaline or granular casts frequently contain oil-globules. Blood-casts,
made up mostly of blood-corpuscles, or else having the latter adherent,
especially characterize the early stage of acute desquamative nephritis.
They result from intense arterial hyperemia or venous congestion.
Purulent casts are rare, and indicate the bursting of a renal abscess.
Hyaline casts have sometimes been found in non-albuminous urine;
and on the other hand, kidney disease may exist (although it must be
very rare), without casts. A few casts may occasionally be found in
heart disease, fevers, or in any condition which may cause sufficient
congestion of the kidneys to make the urine albuminous, and it is not
an unheard-of thing to find a cast now and then in the urine of a per-
son in health. Still, on the whole, it is not strange that physicians in
general look with considerable trepidation on casts in the urine of
their patients.
AN
DISEASES OF THE RESPIRATORY ORGANS.
A. DISEASES OF THE NASAL CAVITY.
BY LUCIUS D. MORSE, M.D.
ACUTE CATARRH OR CORYZA.
Synonyms.-(Greek) xutappoos; (Latin) Catarrhus nasalis, Stillici-
dium narium; (Scientific) Gravedo, Rhinitis, Blennorrhoea nasalis;
(French) Catarrhe nasal, Rhume de cerveau, Enchifrencment; (Ger-
man) Schnupfen; (Italian) Catarro; (Vulgar) in old English, Pose
or mur, whence murrin or murrain; modern English, running at the
nose, cold in the head, snuffles, etc.
Definition. An acute inflammation of the pituitary membrane,
attended by an increase of the habitual secretion, which is more or
less changed in character.
The term catarrh is derived from the Greek words xata, down or
downwards, and pew, I flow, and is applied to a discharge of fluid from
any mucous membrane.
In America and England, the tendency of medical authors is to
restrict its use to inflammation of the air-passages alone; while the
French extend it to that of all mucous membranes, attended by in-
crease in the habitual secretion.
In the word catarrh are embalmed the notions of the old pathologists
who regarded catarrhs as a flux of humors, which, falling down from
the head, escaped through the mucous membranes. Popularly, but,
as we have seen, without precision, the term catarrh is applied, un-
qualifiedly, to an inflammation of the membrane lining the nose. If
the word nasal, however, be prefixed, we have in nasal catarrh a per-
fectly unambiguous expression.
The word coryza, from the Greek xopus, the head, and ew, to boil,
taking cognizance of that peculiar boiling, stewing sensation in the
nose and frontal regions with which many victims of the complaint
under discussion are painfully familiar, has been preferred by some
writers to the terms just mentioned.
On the score of exclusiveness and restricted application, the choice
is, perhaps, a good one; but, certainly nothing is gained when it comes
to etymological signification.
In a brochure on catarrhal affections of the nose, published some years
ago, the writer restricted his employment of the word coryza to acute
cases, or those which would fall under the popular designation of
DISEASES OF THE RESPIRATORY ORGANS.
103
"cold in the head." This nomenclature has its advantages, and is
certainly justified by the derivation of the word. We shall adhere to
it in this article, understanding, of course, that coryza may supervene
at any time in the progress of a chronic catarrh.
History. Catarrhal affections can claim an antiquity as great as
that of the human race itself; indeed, they were coëval with the first
mucous membrane. Most other diseases are parvenu by the side of
these great, original ailments, planted, as it were, in the very nature of
the tissues which they affect.
The old pathologists thought that the discharge in catarrh came from
the brain, and they actually named a glandlike body occupying the
sella turcica of the sphenoid bone the pituitary gland, believing that
it was responsible, in a great measure, for the deluging defluxions
which poured from the nose. It was not until the middle of the sev-
enteenth century that Schneider exposed the fallacies of the old doc-
trine, and cleared the subject of much of the doubt and uncertainty
which had hitherto shrouded it.
Catarrh figures quite extensively in the medical works of a few gen-
erations ago, but it is, usually, considered in a general way, much
stress being laid upon the constitutional symptoms, and very little upon
the local phenomena manifested.
Etiology.—The causes of acute nasal catarrh are innumerable.
Some children are even born with coryza, and many develop it in the
first hours of post-natal life.
The mucous membrane of the nose is, in the very nature of things,
more exposed to external influences than any other similar tissue of
the body. It seems to be correspondingly more liable to disease.
Sudden changes of temperature, either from hot to cold, or the reverse;
inhalations of dust and of irritating vapors, as in manufactories and
laboratories; sudden arrest of the perspiration by exposure to a draft;
and getting the feet wet, may be mentioned among the most frequent
causes. Many persons are so constituted that going with cold, damp
feet, for even a few minutes, will originate a vigorous coryza. Others
can never stand at an open window, or go bareheaded to the street-
door through a cold breezy hall, without suffering an acute attack of
catarrh.
There is good reason to believe that the suppression of chronic erup-
tions by means of washes and salves is also, frequently, productive of
catarrhal troubles. The eruptive fevers-small-pox, scarlet-fever, and,
notably, measles-are frequently attended by inflammation of the
various mucous membranes, producing, now and then, aggravated
catarrhal affections of the stomach, throat, nose, and ears. Often, too,
the origin of a catarrh must be sought for in remote organs of the
body. Perhaps, the great emunctories, the skin, the liver, or the kid-
neys, fail to perform their functions properly, leaving effete matter to
104
A SYSTEM OF MEDICINE.
be thrown out through the mucous membranes, thus giving rise to
persistent defluxions.
Full, or even medium, doses of mercury, arsenic, potassium, and
iodine, will, very often, occasion severe and persistent discharges from
throat and nose.
There are strong grounds, likewise, for believing that malaria is also
one of the active predisposing causes of catarrhal affections. It exer-
cises a powerful influence upon many constitutions, bringing about,
not infrequently, organic changes in various organs of the body, and
stimulating the mucous membranes to abnormal secretion.
It has been claimed that simple catarrh, or coryza, is contagious;
but efforts which have been made to originate an acute coryza in a
healthy person by applying the morbid products of catarrhal inflam-
mation to an unaffected pituitary membrane, have notably failed.
The adherents of the infection-theory point to the fact that the products
of catarrhal inflammation in mucous membranes, other than the pi-
tuitary, especially that of the genital organs, are highly contagious.
The artificial surroundings of modern civilized life are, doubtless,
in their general action predisposing of catarrhal affections.
Anatomy and Pathology. The anterior nares communicate.
directly with the nasal fossa, two irregular cavities situated in the
middle line of the face, extending from the base of the cranium to the
roof of the mouth, and separated from each other by a thin vertical
partition called the septum. They communicate with the pharynx,
or upper part of the throat, by two large apertures, the posterior nares.
The internal structure of the nose is exceedingly delicate. Each fossa
is supplied with three lamellæ of bone, curved and twisted, known,
technically, as the turbinated bones. These twisted plates, with their
two sides free and covered with delicate mucous membrane, add vastly
to the area of surface contained in the two nasal cavities.
At the upper part of the nasal fosse the membrane is very thick,
soft, spongy, and vascular, and is supplied with numerous mucous
follicles, which exude a secretion by which the surface is protected and
kept in a moist and sensitive condition. It is only this portion of the
mucous membrane which is supplied with filaments of the olfactory
nerve, and which is capable of receiving the impressions of smell. It
is designated specially as the olfactory membrane. Elsewhere, the
nasal passages are lined with a mucous membrane which is less vas-
cular and spongy in structure, and which is called the Schneiderian,
or pituitary, membrane.
Four sinuses communicate with the nasal fossa, viz.: the frontal,
sphenoidal, maxillary, and ethmoidal.
These cavities are lined with mucous membrane, continuous and
identical with that of the pituitary, and, we may add, are frequently
affected, likewise, with catarrhal inflammation.
DISEASES OF THE RESPIRATORY ORGANS.
105
What are the pathological changes which take place during an attack
of coryza or acute catarrh? The pituitary membrane shows symptoms
of congestion and incipient inflammation, with well-marked dryness;
then, swelling takes place, and the hydrostatic pressure in the parts
renders the dilated capillaries unable to perform their functions; the
serum of the blood exudes through the distended capillary walls and
adds to the swelling of the adjacent tissues. The epithelial cells of
the distended membrane become infiltrated and undergo a series of
changes; they take on a distended globular form, entangling granula-
tions of mucin; they are then thrown off, and constitute with mucous
globules and half-formed epithelium the semi-transparent, gelatinous,
bluish-gray discharge. Corpuscles of pus are usually mixed with this
mucus, and give it, according to their number, a more or less opaque,
yellowish color.
Examination of the nasal cavities, by means of the speculum, shows
a remarkable thickening of the soft tissues which cover the inferior
turbinated bone, so that not infrequently it rests upon the floor of the
cavity, at the same time pressing heavily upon the septum. The
membranes are spongy and usually coated with the catarrhal dis-
charge. Owing to the swollen condition of the adjacent parts, the
middle turbinated bone is frequently hidden entirely from view,
while, at other times, only the extreme anterior end is visible.
With the rhinoscope great changes can be detected at the posterior
nares. The turbinated bones are seen to be hypertrophied-some-
times their convolutions are entirely obliterated—of a grayish color,
not infrequently tinged with red. The lining of the post-nasal cavity
is usually in the same inflamed and swollen condition.
As the inflammation gradually subsides, the swelling decreases ;
the discharge becomes thicker and more pus-like. This continues
for a short time after resolution has been well established; it then
gradually assumes a lighter color, becomes more gelatinous and
less copious, to finally disappear entirely in cases which terminate
favorably. The average duration of such an attack is from ten to
twelve days.
Symptomatology.—An acute catarrh or coryza is ushered in by
feelings of dryness and fulness in the nose. This fulness spreads up-
ward to the forehead, producing a dull, frontal headache. Irritation
of the mucous membrane now manifests itself. There are itching and
tingling sensations in the nose, frequently attended by spells of sneez-
ing. The tumefaction often becomes so great that the nose is her-
metically sealed (stenosis) on one or both sides, obliging the patient to
breathe in whole or in part through the mouth, and giving rise to the
familiar nasal twang of speech. Rigors and slight fever, with loss of
appetite, not infrequently accompany the symptoms described, the
106
A SYSTEM OF MEDICINE.
severity of the constitutional disturbances varying with the intensity
of the local inflammation.
Owing to the stoppage of the nose, the sense of smell is more or less
completely lost, and sympathizing with this condition, the gustatory
sense likewise becomes obtuse. Many patients complain, conse-
quently, that everything tastes alike to them. The first stage of dry-
ness, irritation and tumefaction of the nasal cavities is of short duration.
The second stage is attended by a more or less free discharge of
thin, serous, acrid fluid which frequently irritates, by contact, the nos-
trils and the lip over which it flows.
The patient is tormented by the constant "dripping," and has fre-
quent recourse to blowing of the nose, which often aggravates the
general condition of malaise, and produces a discharge of blood from
the inflamed and sensitive membranes.
The discharge of mucus undoubtedly proceeds from the entire
pituitary membrane, and not from the glands, as was taught by the
older pathologists. The quantity is sometimes astonishing; but it
must be remembered that the secreting surface is much more extensive
than appears at first thought, owing to the height of the nasal cavity,
of the adjacent sinuses, and to the extensive convolutions of the turbi-
nated bones.
The frontal headache of catarrh is occasioned by the swelling and
turgescence of the pituitary membrane lining the frontal sinus, the
ethmoid and the sphenoid cavities, which closes the openings into the
nasal cavity, and thus, penning up the secretions, produces pressure
upon the nerves, and consequently pain. Sometimes an excrutiating
neuralgia supervenes, which tortures the patient almost beyond the
point of endurance. Occasionally, too, the inflammation spreads from
the post-nasal cavity into the Eustachian tubes, producing hardness of
hearing and very disagreeable sensations in the ears. The eyes fre-
quently sympathize with the general irritation, and become red and
watery, the patient complaining of burning and stinging sensations in
them.
As the case progresses, the discharge from the nose becomes thicker
and less copious, the secretions frequently dry up in the nasal cavities,
producing large crusts which are often dislodged with considerable
difficulty. Sometimes the discharge at this period is of a greenish
color and exceedingly offensive, through long retention in the nose.
The "snuffles," or coryza of infancy, is a complaint which now and
then becomes exceedingly threatening to the welfare of young and
delicate infants. Owing to the swelling in the narrow nasal fossæ,
these passages become hermetically sealed, so that the child is com-
pelled to breathe entirely through the mouth. In such cases a feeling
of suffocation causes the little sufferer to relinquish the breast or the
nursing-bottle with cries of distress, almost as soon as it has been.
DISEASES OF THE RESPIRATORY ORGANS.
107
7
placed to its mouth. The nurse often attributes this action to soreness
of the throat and difficulty of swallowing, when the seat of the trouble is
entirely in the nose. If this condition is not soon relieved, the child,
although hungry and eager to nurse, will become discouraged by its
frequent but ineffectual attempts to secure nourishment, and begin to
manifest a growing irritability and petulancy. Flesh and strength
disappear rapidly under such circumstances, and instances of a fatal
termination have been recorded.
Diagnosis and Prognosis.-The phenomena attending acute.
catarrh or coryza are so pronounced and unmistakable, when the af-
fection has become well established, that there is little chance of either
the patient or the physician committing an error regarding the nature.
of the trouble.
A recognition of the complaint in its earliest stages may be, at times,
somewhat difficult; but usually, the swollen appearance of the face,
the heaviness of the eyes, the already developing huskiness of voice,
and the nasal twang of speech, with the accompanying lassitude and
general feeling of discomfort, leave no room for doubt.
Usually speaking, this complaint is attended with very little dan-
ger. In very severe cases, however, particularly when improperly
managed, or aggravated by repeated applications of cold, it sometimes
passes into a pneumonia attended by grave symptoms.
It must be allowed, too, that, in cases where the Eustachian tubes
have become affected, the danger to the hearing apparatus is often
considerable.
Instances of catarrhal ophthalmia, occasioned by extension of the
morbid process from the nasal cavities to the eyes, are of frequent oc-
currence. It is to be remembered, likewise, that repeated attacks of
acute catarrh predispose the patient to chronic disease of the parts.
affected, and that the prognosis becomes more serious with each re-
curring attack.
Preventive Treatment.-The susceptibility of some persons to
colds must be overcome by building-up their general health and by
paying close attention to their dress. The latter should be warm
(woollen is preferable, except in hot weather) to protect the body and
to secure an equal circulation. Each individual must be a law unto
himself. What would prove too much covering for one person would
not be sufficient for another. However, a moderate excess of clothing
is far from being as objectionable as a deficiency, especially in case of
the old and feeble. Let the exercise be vigorous enough to keep up a
good circulation and a pleasant feeling of warmth.
The feet, by all means, should be kept warm and dry. When mud
and slush are to be encountered, gum overshoes should always be
worn. The neck should not be bundled up with "comfort" or fur
collar, which induce perspiration, almost certain to be checked when
108
A SYSTEM OF MEDICINE.
the wrapping is thrown off upon entering a room, thereby opening the
way for the induction of cold.
A morning sponge-bath in cold water, followed by vigorous rub-
bing, is an excellent means of invigorating the circulation, and ren-
dering the body less susceptible to the influence of the cold air during
the day. If the full sponge-bath proves too severe, and the system
does not react well, the half sponge-bath, from the neck to the waist,
may be substituted,-always followed by vigorous rubbing. The
sleeping-room should be well ventilated, with studious exclusion of
drafts of air. An open grate with a little fire makes a superb ventila-
tion.
Persons who are susceptible to cold need to watch carefully the
digestive functions; indigestion greatly increases the liability to take
cold. A nourishing and generous diet is always to be recommended,
but overloading the stomach should be scrupulously avoided.
Homœopathic remedies frequently aid in breaking up a constitu-
tional tendency to take cold, especially when supported by a faithful
compliance with the hygienic recommendations made. We append
the indications for a few sterling remedies in the way of prophylaxis.
Alumina.-This remedy is of particular efficacy in case of old people who
take cold from the least exposure to a draft of cold air. Such patients are frequently
afflicted with obstinate constipation.
Calcarea carb.-Useful in persons of leucophlegmatic temperament, who are
liable to take cold at every change in the weather. Especially indicated in case of
teething children, who are subject to colds in the head, attended by oppressed breath-
ing. Infants who do not assimilate their food well, and have swelling of the glands
of the neck; adults who suffer much from cold, damp feet.
Nux vomica.-Useful in overcoming extreme susceptibility to cold in persons
who are subject to frontal headaches and attacks of vertigo, occasioned by deranged
stomach. Likewise, in persons whose catarrhal attacks are fluent during the day and
dry at night; the symptoms are worse in the morning, and the patients are troubled
with constipation. Always useful where the patient has taken freely of so-called
tonics, or has employed drastic medicines
Pulsatilla should be considered in case of persons of a mild disposition and
phlegmatic constitution. It is especially indicated as a prophylactic of taking cold
where the catarrhal attacks are attended with pronounced derangement of the diges-
tive functions; also when the eyes and ears are prominently affected.
Sulphur.—Suitable in persons who suffer from an unhealthy condition of the
skin, shown by roughness, cracking or a scaling of the cuticle, chilblains, nettle-rash,
etc.; often, in cases where Sulphur will prove of service, there is an herpetic saddle
across the nose, or the patient complains of a congested condition of the nose, with a
tendency to bleed.
Curative Treatment.-Our ingenious brethren of the old school
admit that a coryza or acute catarrh, which has been thoroughly
established, must run its course. With homoeopathic treatment, how-
ever, such cases may be cut short and their severity greatly amelio-
rated at any stage. At the very outset of an acute catarrh or coryza, while
the chilling depression and languor, which are generally the precursors
of cold, are still present, CAMPHOR is the remedy, par excellence, and will
often abort the whole trouble. From one to three drops of the strong
DISEASES OF THE RESPIRATORY ORGANS.
109
tincture, according to age, should be given on a lump of sugar, every
quarter of an hour until reaction sets in and the patient experiences a
comfortable degree of warmth. If, however, this preliminary stage
has already passed, Camphor affords no help, and the selection of
some other remedy must be made.
Aconite.-Feverishness, swelling and congestion of the Schneiderian membrane;
a painful sensation of heat and smarting is felt in the affected parts; short, dry cough
from tickling in the larynx; later, profuse lachrymation; eyes feel as if full of sand.
Attacks experienced in dry, cold weather.
Allium cepa.-Lachrymation, profuse watery discharge from the nose, with
sneezing; acrid, burning discharge, excoriating the upper lip; cough when inhaling
cold air; great irritation and tickling in the larynx; dull headache, worse in the
evening, better in the open air.
Arsenicum.-Great chilliness and prostration, patient wants to be by the fire
all the time; stoppage of the nose, with a copious discharge of acrid watery mucus,
accompanied by burning of the nose internally and externally; intense thirst, drink-
ing little and often; restlessness at night; catarrh complicated with asthmatic dyspnœa.
Calcarea carb.-Useful in the gravedo neonatorum or coryza of young in-
fants, especially in cases where the leucophlegmatic temperament is pronounced;
flabby and ill-nourished children with large heads.
Chamomilla.-Acrid coryza, from checked perspiration; chapped lips with
redness of the nostrils, and excoriation or soreness under the nose; chilliness with
feverish heat; hoarseness and cough, with rattling of mucus in the chest; snuffles of
infants;
children very irritable, want to be carried all the time.
Euphrasia.-Excessive discharge of watery mucus from the nose; confusion in
the head, with redness of the eyes and eyelids, and copious secretion of burning tears;
photophobia; profuse fluent coryza, with cough and expectoration only in the morn-
ing; eruptions in the wings of the nose.
Gelsemium.-Bland, watery discharge from the nose, with tingling in the
nasal passages; incipient cold with chills; undeveloped or suppressed catarrh; fever
without thirst; soreness in the throat and chest. Epidemic influenzas, with some
fever. Liability to take cold with every change in the weather.
Hepar sulphur.-Swelling of the nose, which is painful like a boil. Nasal
discharge is thick and pus-like, sometimes tinged with blood. Catarrh confined to one
nostril. Every exposure to cold causes a fresh attack. Roughness and scraping in
the throat. Hoarse, croupy cough with loose, choking phlegm. Headache, aggravated
by the slightest motion.
Hydrastis canadensis.-The remedy for fluent coryza with free watery
discharge from the posterior nares and post-nasal cavity into the throat; useful in
cases where Sanguinaria seems indicated, but fails to relieve.
Pulsatilla.-Thick yellow or greenish mucus from the nose; mucus mixed with
clots of blood; sneezing; loss of taste and smell; chilly feelings toward evening.
Patient wants to be in the open air, feels worse in a warm room; loose cough, with ex-
pectoration of yellow phlegm. Persons of mild, tearful disposition, especially women.
Kali bichr.-Fluent coryza with swelling of the nose and nostrils, and discharge
of tough, stringy mucus. Pressure at the root of the nose; closing stage of catarrh,
when there is discharge of tough elastic plugs from the nose, with headache, alternat-
ing with fluent coryza; cough, with expectoration of tough phlegm, which can be
drawn into long strings; derangement of digestion.
Kali hydriod.-Fluent coryza with very copious discharge from the nose, at
first very thin, watery, and scalding, then thicker; frontal pressure and headache with
lachrymation more or less profuse, and sometimes irritation of the throat; red nose.
Mercurius viv.-Profuse discharge with excoriation, swelling or redness of
the nose; night-sweats, with feverish heat; chronic inflammation of the throat and
tonsils; aphthæ; fetid odor from the mouth; ptyalism; catarrh with salty-tasting ex-
pectoration or with mucons diarrhoea.
Nux vomica.-Fluent coryza in the daytime, with stoppage of the nose at
night. Heat in the head and face, with creeping chills, even when seated by the fire;
inflammation in the frontal cavities, with severe headache; excessive itching in the
110
A SYSTEM OF MEDICINE.
nose, with expulsion of bloody mucus. Dry coryza of infants. Catarrhal headaches;
constipation with urging to stool; symptoms worse in the morning.
Sambucus nigra.—Suffocative catarrh of infants; nose obstructed by a thick
mucus; child can hardly nurse, and starts frequently from sleep; hoarseness, with
much tough phlegm in the larynx; attacks of suffocative coughs in children, worse
after midnight.
Sanguinaria.-Profuse watery coryza; the nose continually dripping, attended
often by spasms of sneezing, with sensations of painful rawness; stinging and excoria-
tion in the nasal passages and throat.
sticta pulmon.-Severe coryza; sneezing, headache, and conjunctivitis, with
burning in the eyes. Primary discharge a hot, irritating, watery mucus, which often
changes to a thick, greenish or bloody matter. Dryness of the throat with painful
deglutition; aggravation at night.
Sulphur.-Coryza with discharge of clear water in the open air, and obstruction
in the room; loss of taste and smell; red blotches on the face; dry scabs in the nose,
with tendency to bleeding when they are removed; lips dry and cracked, with ex-
coriation of upper lip, and herpes at the corners of the mouth. Extreme liability to
take cold.
Remedies to be Consulted. Consider also the following reme-
dies, with especial reference to complications: Bell., Merc. jod., Phyto-
lacca, when the throat is prominently affected. Graph. when the in-
flammation extends into the Eustachian tubes. Argentum nitricum,
Euphrasia, Bell., Ignatia, if the eyes are prominently affected. Plant.
major, should there be severe toothache with the catarrhal trouble.
Bell., Phos., Spongia, in case the larynx is involved.
In cases of acute catarrh refer also to Esculus hip., Ammonia,
Cimicifuga, Dulcamara, Ipecac., Lachesis, Lycopodium, Natrum mur.,
Rumex.
CHRONIC CATARRH.
Synonyms.-Rhinangia, Chronic rhinorrhoea, Coryza chronica,
Ozæna benigna; (German) Stockschnupfen; (French) Catarrhe nasal
chronique.
Definition. A chronic inflammation of the Schneiderian mem-
brane with increase or decrease in the habitual secretions, accompa-
nied, likewise, by changes in their normal physical characteristics.
It is nearly always attended by hypertrophy of the mucous tissues in
the nasal fossæ and narrowing, with more or less obstruction, in the
nasal passages. When the obstruction is pronounced, it gives rise to
the well-known nasal speech.
Etiology. Repeated attacks of acute catarrh weaken the mucous
membrane and render it liable to chronic inflammation, especially in
a changeable climate. The inhalation of the dust-laden atmosphere.
of many manufactories is powerfully conducive to chronic catarrh, as
is also the breathing of the vitiated atmosphere of badly ventilated
rooms. The heating of houses by means of furnaces, instead of open
grates or stoves, has frequently produced nasal, laryngeal and bron-
chial troubles in those who were previously exempt. The excessive
use of stimulants and tobacco, also a rich and highly seasoned dietary,
are responsible for many obstinate catarrhal cases. Venereal excesses
DISEASES OF THE RESPIRATORY ORGANS.
111
and dissipation, in general, add to the number. Indeed, the luxuries
and vices of modern civilized life are, in the end, responsible for the
vast increase in the number of those afflicted with the complaint in
question. Among our forefathers, with their simpler ways, chronic
nasal catarrh was little known.
It must not be forgotten that in a great many instances the catarrhal
trouble is purely symptomatic, being occasioned by disturbance in
some of the great vital organs, or occurring as one of the exponents.
of a deranged and vitiated condition of the system generally; syphi-
litic and scrofulous taints, often, exhibit their activity in connection
with nasal troubles, especially in children.
Pathology. An examination of the posterior nares and vault of
the pharynx, by means of the mouth mirror, shows these parts deeply
reddened in spots, and covered with the products of catarrhal inflam-
mation which is frequently hardened and inspissated. A microscopic
examination of epithelial cells from the inflamed surface reveals a
notable absence of cilia. This is significant, showing that degenerative
changes in the membrane are so rapid as to prevent a healthy organi-
zation and development of the tissues.
Inspection of the nasal cavities anteriorly exhibits the covering of
the turbinated bones thickened and congested. Not infrequently it
is discovered that there is perforation of the cartilaginous septum of
the nose, caused by the patient's persistent efforts to clear from the
walls of the partition the dry scabs and scales which as persistently
reform. Usually, the nasal floor is found to be in a healthy condition.
Symptoms. An acute catarrh or coryza may become chronic, in
any stage of its progress, and continue so for an indefinite period.
This is a point which the practitioner must bear in mind. A great
majority of cases of chronic catarrh, however, manifest the symptoms.
which are found in the second and third stages of the acute variety.
The discharge is generally quite thick and yellowish, though some-
times the color is greenish. In some cases the secretion will be
free for a few days, followed by a period of dryness, when plugs and
scabs are formed in the nasal cavities, their expulsion requiring con-
siderable exertion. Dull, frontal headache is often present, and the
patient's bowels are generally constipated, though sometimes the re-
verse condition obtains. Dizziness is a frequent symptom, and sneez-
ing, especially in the morning, is complained of bitterly by some
patients, while in others this form of irritation is entirely absent.
There is, in many cases, great dryness of the nostrils-the secretion
seeming to form far back in the nasal fossæ; especially does this occur
in instances where the catarrhal inflammation has invaded the vault
of the pharynx, giving rise to the highly unpleasant symptom of mucus
dropping down into the throat. In such cases patients often suffer
with sick stomach, caused by the tenacious discharge sticking in the
112
A SYSTEM OF MEDICINE.
pharynx and bringing about retching and vomiting through mechani-
cal irritation. Sleep is often disturbed by the mucus dropping into
the throat and causing a choking sensation. The clearing out of the
nares, every morning, by blowing of the nose, hawking and coughing,
is a task of considerable magnitude. If the calibre of the nose is large,
a considerable amount of swelling will be tolerated without giving rise.
to nasal speech. Occasionally, patients are tormented by a sensation
of pungent smell in the nose, disagreeable or otherwise. This is a
pretty sure sign of sharp irritation in the olfactory portion of the
Schneiderian membrane. Often, these smells are experienced by pa-
tients whose olfactory sense is very much blunted.
Complications. Sometimes, in acute and, likewise, in chronic
catarrh, the inflammation spreads from the throat along the Eustachian
tubes into the middle ear, producing much pain and discomfort, and
now and then interfering materially with the sense of hearing. In
fact, throat deafness is far more common than the uninformed would
suspect.
The same tendency to spread, which carries the inflammation into
the Eustachian tubes and thence into the middle ear, often causes an
invasion of the lachrymal ducts and inflammation of the eyes. As we
have seen, the frontal and maxillary sinuses are often involved.
It has already been remarked that the post-nasal cavity is, frequently,
affected, and as we have many times observed in practice, the morbid
action frequently abandons the nose to locate itself in the vault of the
pharynx, whence it is likely to spread, leisurely, downward. There
is some authority for believing that chronic nasal catarrh predisposes
to frequent attacks of erysipelas of the face in those who incline to this
species of inflammation.
Diagnosis.—A careful inspection of the nose should be made
before pronouncing upon a case. Use the speculum and mouth mirror
having previously cleaned out the pharyngeal vault and, if necessary,
the nasal fossæ by the use of the post-nasal syringe with warm salt
water. After the use of the syringe, the patient should blow the nose
thoroughly, so as to dislodge any concretions or tenacious shreds of
mucus which may still cling to the parts. If polypi, or ulcerations, or
hypertrophy of the turbinated bones are present, these affections can
readily be detected in the majority of cases. The bearing of the stru-
mous and syphilitic diathesis should be constantly borne in mind in
the examination of catarrhal patients. The personal appearance of
the sufferer, and the concomitant symptoms, together with a history of
the progress of each case, will throw much light upon the probable
cause. The character and copiousness of the discharge should, like-
wise, be carefully ascertained, as this furnishes a valuable means of
learning the stage of the disease and the extent of the inflammation;
in many cases, too, the nature of the discharge will decide the remedy.
DISEASES OF THE RESPIRATORY ORGANS.
113
Prognosis. Physicians of large experience in the treatment of
chronic nasal catarrh soon learn to become guarded in their prognosis.
Often, severe cases yield much more readily than others which are ap-
parently milder. In cases which have run for years, and in which the
nasal symptoms proper are attended by concomitant symptoms show-
ing marked disturbance of the general system, a long course of treat-
ment is, frequently, necessary to obtain permanent relief. In cases in
which loss of smell and impairment of sight and hearing are threat-
ened by extension of the disease, the prognosis must be guarded. Gen-
erally speaking, the success of the treatment depends largely upon the
common sense used by the patient. A reckless and thoughtless person
can easily undo, in a few hours, the good derived from weeks of the
most skillful and judicious treatment.
Preventive Treatment.-Everything mentioned under this head
when considering the prophylaxis of acute catarrh, might be repeated
here with increased emphasis. It must be remembered that a vital
interest centres in this branch of the subject, from the fact that catarrh
of the nasal cavities and vault of the pharynx has proven to be in
very many cases the avant courier of laryngeal and pulmonary phthisis;
the patient had best be informed of this fact, if he proves at all re-
fractory.
A nutritious diet; the careful avoiding of pastry and highly-sea-
soned dishes; woollen clothing in cold weather; ample protection to
the feet at all seasons and, especially, against wet weather; the sponge-
bath in cool water, followed by vigorous rubbing; abstinence from
stimulants; control of the sexual passion; ample ventilation of the
sleeping-room; plenty of outdoor exercise, and a well-regulated life,
will fortify the system against the invasion of chronic catarrh. The
question of diet and of dress will, in many instances, tax to the utmost
the ingenuity and the judgment of the physician. At one time the
writer made a practice of recommending to all his catarrhal patients,
indiscriminately, the use of milk, oatmeal, and cracked wheat as chief
items in the diet list. To his surprise, he found that these articles, so
nutritious and wholesome, in theory, proved quite the reverse in a
great many instances, when put to the test. It was not long before he
made the discovery that oatmeal and cracked wheat, especially when
cooked on the American plan, require a vigor and staying power, so
to speak, in the digestive functions, which many of his patients were
far from possessing or, indeed, ever acquiring.
As to milk, it was forced upon his consciousness at last that to many
stomachs it is a veritable poison. Tea or coffee, if used at all, should
be taken in moderation. I believe that their wholesale condemnation
answers no good purpose. A wide latitude in diet must be allowed,
encouraging the patient to adhere to the use of those articles of food
which he finds are assimilated kindly by the stomach, and to aban-
VOL. I.-8
114
A SYSTEM OF MEDICINE.
as
don those which occasion symptoms of indigestion; it is well,
the general health improves, to test the strength of the stomach from
time to time by a return to hearty food. By this course the digestive
powers may be strengthened, as a muscle is strengthened through ex-
ercise. As a rule, the adult who takes three regular full meals a day,
unless he be employed in severe manual labor, eats a larger amount
than is required.
So, too, when we come to give directions regarding the dress of the
patient, it will be found that what one person can wear with com-
fort, another finds extremely obnoxious, if not positively injurious.
Occasionally, flannel worn next to the skin produces an almost intol-
erable irritation and discomfort. In such cases, cotton gauze under.
wear may be placed between the skin and the woollen clothing.
For observations concerning the use of remedies as prophylactics,
the reader is referred to the preceding article on acute catarrh.
Treatment. The old method of treating chronic nasal catarrh
almost exclusively by local applications is open to grave objections.
Such treatment does not cure the diseased condition. Then, too, the
use of the douche, the syringe, and the inhaler, often does more harm.
than good by irritating adjacent healthy tissues, while the affected
parts are left in statu quo, or made a great deal worse.
Concerning the nasal douche, too much can hardly be said in its
condemnation. The liquid employed with this apparatus frequently
passes into the Eustachian tubes, giving rise to trouble in the ear, in-
cluding deafness. The original notion that the stream of medicated
water which passes in at one nostril and flows out at the other, cleanses
the nasal cavities, and at the same time brings the medicament in
the lotion into contact with the diseased tissues, is erroneous in point
of fact. The stream simply passes along the floor of the nasal cavi-
ties, and does not penetrate into the upper portion of the fossæ.
The post-nasal syringe, in the hands of a skillful operator, is of much
more utility when it is desired to cleanse the obstructed cavities, and,
used in conjunction with a good spraying-apparatus, enables the prac-
titioner to remove quite satisfactorily the secretions which would,
otherwise, prevent a thorough examination of the affected parts. As
to the therapeutic advantages of these appliances, together with snuffs,
inhalants, etc., the writer's experience has been such as to discourage
their employment. The spraying-apparatus is, perhaps, the least ob-
jectionable of all the various means for applying local treatment, and
its moral effect on the patient, in the way of inspiring him with hope,
through the tangible efforts which are being made for his relief, may
frequently justify the physician in its use. For this purpose a medi-
cated lotion may be prepared by adding to an ounce, or two, of warm,
soft water three or four drops of the fluid-extract of hydrastis cana-
densis or of sanguinaria, or of ten to twenty drops of a dilution of the
DISEASES OF THE RESPIRATORY ORGANS.
115
homœopathic remedy which is being administered internally. This
sort of local treatment is, at least, harmless.
In the treatment of chronic nasal catarrh the physician must re-
member that he is confronted by the local manifestations of a consti-
tutional disturbance. Each case should be most carefully investigated,
and all the idiosyncrasies of the individual patient unearthed.
This done, the course of treatment decided upon must be followed
patiently, day after day, and week after week, unless some exigency
arises which calls for a change.
The patient should be encouraged by all legitimate means, but, at
the same time, patience and pluck should be instilled at every oppor-
tunity.
The frequent change of remedies is not to be encouraged. If, how-
ever, careful inquiry fails to elicit acknowledgment of improvement
in some of the symptoms after the use of any given remedies for ten
or twelve days, a revision of the case should be undertaken, and other
remedies prescribed.
At the beginning of treatment, it has been my habit to give from
three to four doses of medicine each day, say, an hour before each
meal and at bedtime. I sometimes give a single remedy, and some-
times alternate two remedies. Alternation seems to work satisfacto-
rily in those cases in which there is much headache, or in which con-
stipation and hæmorrhoids are present, or pronounced skin-disease is
discovered. I would further remark that, for a number of years past,
I have administered to my catarrhal patients, almost exclusively, the
low potencies, ranging from the 1 to the 6.
The question of a change of climate in stubborn cases of catarrh
often forces itself upon the practitioner.
Such a change is sometimes advisable. People who live in the in-
terior are often improved wonderfully, even to the disappearance of
all catarrhal symptoms, by their removal to the sea-coast, and those
who have dwelt on the plain often receive much benefit by a sojourn
in the mountains, and vice versa. In most cases, however, nothing
short of a permanency of residence will yield permanently beneficial
results. A return to the old habitat is likely to be followed, in a short
time, by a development of the former catarrhal trouble, and in its
former degree of severity.
The same applies to visits to mineral springs. I have known many
cases where a chronic catarrh has disappeared, as if by magic, under
the use of the thermal waters of Arkansas, only to return as soon as
the patient had reached home. Some patients are, undoubtedly, per-
manently benefited by these changes, but they are rare, and instances
are not wanting in which change of climate decidedly aggravated the
disease.
116
A SYSTEM OF MEDICINE.
Therapeutics.—Alumina.-This remedy has proven efficacious in combating
scrofulous taint, coupled with nasal or aural discharges, and in modifying the results
of an inherited predisposition to catarrh.
Its prominent symptoms are great irritation of the Schneiderian membrane, with diɛ-
charge of thick yellowish mucus, or expulsion of yellowish-green scabs; stoppage of
the nose; snapping in the ears when chewing or swallowing, caused by partial occlu-
sion of the Eustachian tubes.
Pain in the root of the nose, chronic inflammation of the fances, with accumulation
of tenacious mucus in the throat
Alumina is a valuable remedy for old people, and should be considered in all cases
of catarrh where there is obstinate constipation from atony of the bowels, so that even
soft stools are passed with difficulty; useful in catarrhal affections occurring among
painters and workers in lead.
Alumina patients are generally better in the open air, but take cold from the
slightest exposure.
This remedy makes a powerful and long-lasting impression upon the mucous mem-
branes of the entire body. Its effect is very marked upon the female organization,
especially in case of uterine derangements and leucorrhoeal discharges which alternate
with catarrh of the nose and throat.
Argentum nitricum.-Violent itching in the nose; ulcers in the nose
which become covered with yellow crusts. Scurfs in the nose which excite pain, and
are followed by slight bleeding when detached; stoppage of the nose at night, with
much itching. Bloody and purulent mucus discharged from the nose. Dulness of the
sense of smell. Coryza with constant chilliness; lachrymation, sneezing, and violent
stupefying headache.
Argentum is a good remedy in both acute and chronic catarrh of the nasal passages.
The pharynx, larynx, and EYES will nearly always be found more or less affected when
this remedy is indicated.
Arsenicum.-Discharge of a burning, acrid character, causing a biting sensation
and soreness in the nose.
There is frequent stoppage of the nasal passages, accompanied by a stinging, burn-
ing sensation, and succeeded by a fluent coryza. There is, usually, great restlessness
and chilliness, even in the chronic cases; the sufferer hugs the fire, and is better in a
warm room, and worse in the open air and at night. Sleeplessness with beating in
the forehead and, sometimes, nausea; no thirst, or desire to drink often, but little at a
time. The ears are sometimes affected, and one or both become closed during
deglutition.
The catarrhal symptoms often affect the eyes, producing a discharge of excoriating
tears. This drug is especially valuable in cases of thin and illy-nourished subjects,
and in those who have been long subjected to malarial influences.
Arsenicum iodatum.-The Iodide of arsenic is applicable in case of per-
sons with pale, delicate skin, enlarged tonsils, defective assimilation; tendency to pas-
sive œdema, shown by puffiness of the eyelids. It is, also, strongly indicated in the
tuberculous diathesis, upon which has been grafted a nasal or laryngeal catarrh. The
discharge in these cases is generally copious and thin, but sometimes scanty and thick ;
now and then tenacious and frothy.
Discharge of very irritating and corrosive watery mucus which burns the nostrils
and lips, attended often with alternate chills and heat. Epidemic influenza.
Otorrhoea complicated with catarrh, with fetid and corrosive discharge. A burning
sensation in the nose and throat is quite characteristic.
The Iodide of arsenic possesses a very considerable range of action, and is a valu-
able remedy in many cases in which there exists enlargement of the tonsils and a ten-
dency to induration of the glands. I have also found it of wonderful efficiency in
catarrhal affections grafted upon a phlegmatic temperament, where the constitution
has received a profound malarial impression. In the treatment of chronic catarrh it
is far more useful than the simple Arsenic.
Aurum. This remedy is indicated in caries of the bones of the nose, with fetid
discharge of greenish or yellow pus. Salty-tasting, watery discharge through the pos-
terior nares.
Nostrils closed with hardened scabs. Loss of smell and frequent dis-
charge of blood from the nose; swelling of the nose after walking in the open air;
nasal bones are painful to the touch; fetid otorrhoea with catarrh; coryza sometimes
violent and profuse; habitual nasal tone of voice; drinks flow back again through the
nose.
It is one of the first remedies to be considered after the abuse of mercury in syphil-
DISEASES OF THE RESPIRATORY ORGANS.
117
itic ozæna, and in catarrhs which appear only in winter. The mental symptoms are
characteristic There is great depression of mind; the patient constantly bemoans his
condition, and thinks everybody knows his complaint; he shuns society on account of
the disagreeable odor from the nose. When the scrofulous diathesis is marked, the
Muriate of gold is preferable to the metal. The settled melancholy, hopelessness, and
loathing of life are very characteristic indications for the use of this remedy. The
mental symptoms of Nitric acid are somewhat similar to those of Aurum, but fall short
of the intensity possessed by the latter.
Calcarea carbonica.-A most useful remedy in combating profoundly-
seated constitutional taints. It should always be carefully considered in cases of chil-
dren of a scrofulous diathesis and of phlegmatic temperament, with affections of the
glands and a chronic discharge from the ears or nose. The symptoms are usually of a
sub-acute character. Dampness and coldness of the feet, and a feeling as though the
stockings were always wet, are prominent. The nasal discharge is usually thick and
pus-like, but sometimes thin and watery. There is frequently dryness of the nose at
night, with moisture during the day. Often the catarrhal symptoms are not confined
to the nose, but the pharynx and larynx are also involved, and there is present a pecu-
liar raw feeling in the vocal organs, accompanied, not unfrequently, by chronic hoarse-
ness. Inflammation, swelling, and redness of the anterior portion of the nose; eruption
on the nose; sore, ulcerated nostrils; very bad smell in the nose; itching of the eyes,
with lachrymation.
Calcarea is exceedingly useful in women of a leucophlegmatic temperament, when
catarrh exists in connection with leucorrhoea or menstrual irregularities. It is also a
great corrector of malnutrition, manifested either by emaciation or excessive obesity.
The pale, wrinkled face in the one case, and the colorless, bloated visage in the other,
are equally characteristic of this remedy. The leucophlegmatic temperament is, how-
ever, the touchstone of its applicability. Where this temperament is pronounced,
long-lasting catarrhal troubles of nearly every species fall within its province. Chil-
dren with chronic discharges, either from the nose or the ear, present evidence of a
constitutional hereditary taint which must be combated. Here, Calcarea becomes
the foremost remedy, although Sulphur, Silicea, Kali bichrom., and Mercurius will fre-
quently come into play.
When there is enlargement or induration of the glands, especially about the head
and neck, discharge copious, of a light straw color or even yellow, Mercurius will
prove of great benefit. When there is periodical ejection of plugs of yellow, sticky
mucus, Kali-bichrom. generally is most effective. In treating children who are subject
to boils and eruptions, with skin of a dirty, unhealthy appearance, the writer has inva-
riably begun treatment with Sulphur, regardless of other symptoms.
Graphites.—Catarrh, accompanied with inflammation of the fauces and stoppage
of the Eustachian tubes, producing constant desire to clear the nose and throat.
Roaring in the ears and crackling, when swallowing; catarrh of the middle ear
Bloody mucus from the nose, alternating with expulsion of dry scurfs; also discharge
of thick, fetid mucus. The aural symptoms are quite characteristic in this remedy,
and are nearly always produced by stoppage of the Eustachian tubes.
Its curative action is prompt in individuals who are subject to any eruption exuding
from a raw surface, a thin, glutinous, transparent, watery fluid. Graphites has many
symptoms in common with Calcarea carb., Hepar, Silicea, and Sulphur, and should be
carefully studied in those cases where the organism fails to respond to these remedies.
It often follows admirably after Mercurius, and should be carefully considered in cases
of women with tendency to unhealthy corpulence, and in those suffering with men-
strual troubles.
Hepar sulphur.-Swelling of the nose, which is painful like a boil, accom-
panied by catarrh and smarting roughness in the fauces. The bones of the nose
are painful to the touch. The nasal discharge is thick and pus-like, sometimes tinged
with blood. Headache, worse from motion. Catarrh confined to one nostril; every
exposure to cold causes a new attack; cases of ordinary catarrh where Mercurius has
afforded partial relief, and improvement has ceased. Especially useful where the
patient has at some period in life had the itch, or other cutaneous disease, which was
repelled by external applications, such as ointments and washes. Also useful when
there is great sensitiveness; patient is chilled by the slightest draft of air; the least
injury causes ulceration; swollen, indurated tonsils, and hard glandular swellings about
the neck. Useful antidote to abuse of mercury, when characteristic symptoms are
present.
Hydrastis canadensis.-Dropping down of mucus from the posterior nares
118
A SYSTEM OF MEDICINE.
into the throat Raw, excoriated feeling in both nares; constant inclination to blow
the nose.
The fauces feel raw and inflamed. Hacking up of tough yellow or whitish
mucus; tenacious. stringy discharge. Ulceration of the membranes of the nose;
scrofulous ozæna. Aphthous sore mouth; excessive secretion of tenacious mucus from
the mouth; profuse lachrymation. The dropping down of mucus from the posterior
nares into the throat is exceedingly characteristic of this remedy. If constipation of
the bowels and general atony of the system accompany the above symptoms, it will
seldom fail to effect a cure, or at least to produce a favorable change, thus paving the
way for the successful employment of some other remedy. In cases in which the
stomach lacks vigor, the bowels are inactive, and the nose is dripping as if from simple
hydrostatic pressure, its administration will produce strikingly beneficial results. It
is useful in those cases in which apparent ulceration exists with muco-purulent dis-
charge. It is a rival of Kali bichrom. when the discharge is tenacious and stringy,
but has not the virulence nor the persistency of action manifested by the latter remedy.
It acts vigorously upon the posterior nares and post-nasal cavity, and should be con-
sidered when the catarrhal inflammation has involved the Eustachian tubes, and even
the middle ear. It is to be considered when the eyes are involved in the general
catarrhal condition, and in old cases, with torpidity of the liver and a general atonic
condition of the digestive organs.
Kali bichrom.-This remedy is exceedingly useful when the nose, pharynx,
and larynx are involved. It is one of the few drugs which are beneficial in caries
of the bones of the nose, and in combating the constitutional effects of syphilis when
complicated with catarrhal affections of the nose and throat. It is especially suitable
for fat, light-haired people. The symptoms calling for its administration are: Yellow
discharge from the nose, internal excoriation; severe pain across the bridge of the
nose; periodical discharge of tough plugs from the nose, tinged sometimes with blood;
discharge of tough, stringy mucus; destruction of nasal septum; chronic cold in the
head and catarrhal inflanimation of the fauces, with chronic hoarseness, loss of smell,
fetid smell before the nose, headache from suppressed ozæna; catarrh, which is worse
in warm weather, or which involves the mucous membrane of the stomach; loss of
appetite, with nausea on moving about, relieved by lying down.
Mercurius iodatus.-Catarrhal affections of the nose, extending into the
throat. The nasal discharge consists of a tough, white, or yellowish mucus, which
forms chiefly about the posterior nares and in the post-nasal cavity. It is also useful
in those profuse, acrid, long-lasting discharges which excoriate the nostrils and upper
lip. The constitutional symptoms are characteristic, viz.: Tonsils subject to inflam-
mation and ulceration; induration and swelling of the glands; torpidity of liver and
enlargement of the spleen. I have used the Mercurius iodatus with great benefit in
cases in which inflammation of the nasal mucous membrane extended into the lach-
rymal duct and sac. It seems peculiarly adapted to such cases occurring among
children. I have occasionally used it as low as the 1st dec. trit., with prompt relief
in cases where the catarrhal inflammation of the posterior nares ran high, sometimes
involving the entire pharynx.
Mercurius vivus.-Nasal discharge profuse and watery; also, discharge of
greenish, fetid pus from the nose. Liquids which the patient attempts to swallow
pass back into the posterior nares. Chronic inflammation of the throat and tonsils.
In acute attacks, copious discharge of watery saliva, swelling, redness, and soreness
of the nose; night-sweats and feverish heat; symptoms aggravated by warmth or
cold; pains in the limbs; bleeding from the nose during sleep or on coughing; aph-
thæ; fetid odor from the mouth; ptyalism; catarrh, with cough and salty-tasting
expectoration, or with mucous diarrhoea. The roof of the mouth is often dry, and
there is constant inclination to swallow. Catarrh of the Eustachian tubes. Hardness
of hearing; crackling and roaring in the ears, with periodical stoppage of one or both
ears. Swelling and induration of the liver; torpidity of the liver, and heavy, slug-
gish feeling of the entire body; patient worse at night and in a warm room; ex-
periences little relief from perspiration.
Nitric acid.-Useful in persons who have taken a great deal of Mercury. The
discharge is yellow and fetid; often accompanied by swelling of the nose and violent
itching in the parts; sometimes, an ichorous discharge is present. Violent coryza,
with lacerating pain in all the limbs, redness of the tip of the nose. Great sensitive-
ness to the open air; excessive thinness and emaciation of the whole body. It is of
importance in cases in which there are much heart-burn, acid eructations, and other
symptoms of dyspepsia, especially in persons subject to aphthous ulcers in the mouth.
Nux vomica.-Heat in the head and face, with creeping chills, even when
DISEASES OF THE RESPIRATORY ORGANS.
119
seated by a warm fire; fluent coryza in the daytime, with stoppage of the nose at
night; premonitory symptoms of catarrh; inflammation in the frontal cavities, with
severe headache; expulsion of bloody mucus from the nose; excessive itching of the
nose; severe pains in the face; frequently useful where Arsenicum fails to relieve.
Dry coryza of infants.-The writer has found this drug almost specific in many of
those distressing frontal headaches which accompany nasal catarrh. The bowels are
constipated, and the patient feels worse in the morning. It acts, also, to a certain ex-
tent, as an antidote to the injurious effects of the douche and strong medications.
Phosphorus.-Especially suitable to persons of phthisical constitution, who
are subject to catarrhal affections. The particular symptoms indicating its use are:
Swelling of the nose; frequent discharge of blood from the nose (very characteristic);
green-yellow discharge from the nose, with great dulness of the head; catarrh, with
inflammation of the throat and hoarseness. The discharge from the nose is nearly
always tough or thick, and unaccompanied by coryza; weakness of the lungs; fre-
quent hoarseness; tickling cough, brought on by reading aloud, laughing or singing;
cough, with salty expectoration; loss of the sense of smell; fetid smell from the nose;
discharge of burning and smarting fluid from the eyes, especially in the open air. The
patient, nearly always, feels worse when abroad on windy days, and is very sensitive
to cold weather. This remedy is particularly useful in cases where there is neuralgia
of the head and face, headache, worse from stooping.
Pulsatilla.-Loss of appetite; loss of taste and smell; photophobia; feeling of
dulness and heaviness in the head, especially in a warm room, with obstruction of the
nose. The patient is better in the open air; chilliness with absence of thirst; alternate
stoppage and running of the nose, Applicable in cases of green, fetid discharge from
the nose, accompanied with hardness of hearing, as though the ears were stopped up;
affection of the frontal sinuses; bad smell from the nose; pressure at the root of the
nose. More often indicated in women than in men. The mental symptoms are char-
acteristic; the patient is easily moved to laughter or tears; is of a susceptible tempera-
Characteristic derangement of the stomach, with occasional obstinate constipa-
tion. Huskiness of the voice, early in the morning, which passes away after slight
cough and expectoration. Best suited to flabby subjects of light complexion, with
irritable eye-lids and aphthous ulcers in the mouth. Aversion to meats or greasy food.
Useful in catarrhal troubles following measles or other acute diseases.
ment.
Sanguinaria.-Severe, burning heat and redness of the face; much sneezing;
fluent coryza; watery, acrid coryza; catarrhal ophthalmia, with copious watering of
the eyes; beating and humming in the ears; feeling of dryness in the chest, not di-
minished by drinking; sensation as if the throat were swollen up; pain in the breast,
cough, and finally diarrhoea; cold and languid circulation, with great sensitiveness to
atmospheric changes. This powerful drug has a marked effect upon the mucous mem-
branes of the body, particularly of the respiratory tract. It has been used most suc-
cessfully in affections of the nose and throat, when there has been present a sensation
of stinging and tickling, accompanied by irritative swelling of the parts, either with
or without free discharge. It is very useful in cases of torpidity of the liver, accom-
panied by catarrh, especially in persons subject to violent sick-headache or vertigo.
The Eustachian tubes and inner ear fall within its sphere of action, and when deaf-
ness has been caused by catarrhal troubles of the throat it deserves consideration. In
some points it resembles Phosphorus, or Arsenicum, and, remotely, Hydrastis.
Sepia. Swollen, inflamed nose, with sore and ulcerated nostrils; painful erup-
tion on the tip of the nose; feeling of dryness in the nose and fauces; obstruction of
the nose; violent, dry coryza, with roaring in the head and ears. This remedy is
prominently indicated in cases where there is a discharge of green, bloody mucus from
the nose, especially when accompanied by external inflammation of the nose. It is
curative, too, in cases where there is ulceration high up in the nasal fossæ, accompanied
by loss of smell. It acts well in dark-haired, pale-faced women, sometimes presenting
a yellow discoloration of the skin across the nose, resembling very much a saddle. In
women with uterine weakness and menstrual derangements, Sepia is often highly
useful.
Silicea.-Painful, chronic dryness of the nose, or inveterate ulceration of the
Schneiderian membrane, producing an acrid, corroding discharge. Herpetic eruption
about the nostrils, or on the lips. Silicea acts slowly but profoundly, and is adapted
to the scrofulous diathesis, especially when there is induration and suppuration of the
glands or lymphatics in any part of the system. Like Aurum, it reaches those deep-
seated morbid processes which, sometimes, actually destroy the bony structures of the
nose.
120
A SYSTEM OF MEDICINE.
Sulphur.-Chronic obstruction of the nose, attended by formation of hard, dry
scabs; frequent bleeding of the nose; external inflammation; 'illusions of smell;
catarrh with itching eruptions on the skin; excoriation and ulcerations of the nos-
trils; profuse secretion of thick, yellowish, and puriform mucus; boils and eruptions
on the nose; stoppage of the nose, sometimes only one-sided; aphthæ; ptyalism; great
susceptibility to taking cold; great heat of the feet, at night, with burning and itch-
ing. One of the prominent indications for this remedy is an unhealthy condition of
the skin, every little injury suppurating and healing slowly. Like Hepar sulphur.,
it is to be considered in obstinate cases, based upon a scrofulous or so-called psoric
taint, upon repelled itch; the patient is or has been subject to ontbreaks of nettle-
rash; after the excessive use of Mercury.
Consult likewise the following remedies: Amm. brom., Asa fœtida,
Cyclamen, Iodine, Kali hydriod., Lachesis, Lycopodium, Mercurius
biniod., Natrum carb., Natrum mur., Sticta pulmon.
OZÆNA.
Synonyms. (Greek) ofawa; (Latin) Ulcus narium fœteus, Rhi-
nitis ulcerosa, Pyorrhoea nasalis, Coryza entonica seu purulenta;
(French) Ozène, Punaisie; (German) Stinknase.
Definition.-An affection of the pituitary membrane which occa-
sions a very disagreeable breath, the smell being, in many cases, simi-
lar to that of a crushed bed-bug.
History. The exact seat and precise nature of the complaint have
not been definitely settled by pathological investigators. The greater
number of medical writers who mention this distressing ailment,
speak of it as being coupled with ulceration of the Schneiderian mem-
brane. The nomenclature of this disease shows conclusively the views
entertained on this score by those who have written upon it. Recently,
Dr. Carl Michel, of Cologne, has denied the existence of ulceration of the
nasal mucous membrane in cases of true ozæna, claiming that the
greenish scales, which nearly always in ozæna coat the lining of the
nasal cavity, had been often mistaken for ulcers. He teaches that
ozæna consists in purulent inflammation of the cavities of the septum.
and of the sphenoid bone. His reasons for this belief he sums up as
follows: Lack of pathological proof in the nasal cavity; the fact that
the morbid secretion appears in the posterior part of the fossæ and on
the roof of the pharynx, even when the nasal membrane is in a healthy
condition; the pungent, cadaverous odor of the semi-fluid secretion,
proving that it must have been retained in a cavity until decomposi-
tion had set in, mucus secreted from an open surface never giving a
bad odor; the intractableness of the complaint, which continues even
after any co-existing disease of the nasal cavity proper has been cured.
This view of the subject is certainly plausible, and based upon care-
ful clinical investigation.
Ætiology.—The causes of simple ozæna (for we are not now con-
sidering that of syphilitic origin, which will be mentioned under
another head) are exceedingly obscure. The scrofulous diathesis is,
doubtless, often responsible, but the teaching of some writers, that it
is nearly always of such origin, must be taken with some grains of al-
DISEASES OF THE RESPIRATORY ORGANS.
121
lowance. We have seen quite a number of victims who were the very
picture of health, and in whose families no evidence of scrofulosis
existed, not even a case of chronic catarrh. My own view is that, in
the majority of cases, ozæna is the result of frequent attacks of acute
catarrh. Catarrh, sooner or later, from some obscure constitutional
bias, gives rise to an obstinate inflammation in one or more of the side
cavities of the nasal fossæ. The catarrh proper of the nose may dis-
appear, but there remains the smouldering fires of a once general con-
flagration, which continues unobserved its work of destruction. It is a
suggestive fact, too, that the great majority of sufferers from this malady
are attacked when quite young, usually in childhood. Voltolini
taught that sex is an important ætiological factor, and that ozæna is
almost entirely confined to women. Other observers, however, have
noted its more frequent occurrence in the masculine sex. Nearly all
the patients who have consulted the writer have been women and
girls; he hazards the opinion that sex has little or nothing to do with
the genesis of the disease, but that women, being more sensitive to its
unpleasant features than men are, apply more readily for treatment.
Symptomatology and Pathology. The secretion in ozæna is
generally of a yellowish or greenish appearance, though, sometimes, it
is of a peculiar ashy-gray color. Plugs and clinkers of rank smell are
frequently expelled from the nasal fossæ, but, strange as it may seem,
these passages are seldom obstructed; indeed, they appear, in the
majority of cases, more than ordinarily open and free. There is often
much dryness of the throat, and patients frequently complain of nau-
sea and retching, occasioned by the sticky discharge which adheres
tenaciously to the posterior part of the soft palate and to the vault of
the pharynx. Sometimes, patients will eat a hearty meal and then,
in the effort to expel from the throat the tenacious mucus loosened by
the act of mastication, vomit it all up. Frontal headache with loss of
smell is a common concomitant symptom. Taste and hearing seem
little affected. The cartilaginous part of the nose is often swollen, and
patients who have suffered for a long time have usually a yellow,
bilious look which is suggestive of ill health. It must, however, not
be forgotten that some patients appear to be robust and vigorous,
while the exhalations from the nostrils are suggestive of necrosis of
the bone, and sloughing of the parts. The mental condition of patients
affected with ozæna is almost invariably depressed and melancholy,
largely due to the consciousness that their presence is a source of
annoyance to others. The passage of decomposed secretions from the
throat into the stomach exercises a deleterious influence upon that
organ, while the constant breathing of infected air would suggest a
likelihood of constitutional disturbance of some sort, sooner or later.
The question as to whether, or not, absorption of pus ever occurs
from the over-flowing side cavities of the nasal fossæ, has often forced
itself upon my consideration. I see no reason why, in certain condi-
122
A SYSTEM OF MEDICINE.
tions, it may not take place in such degree as to exercise a depressing
influence upon the general system.
Prognosis. All authorities, I believe, agree as to the intractable-
ness of this distressing ailment. Still, it is amenable to treatment, and
there are few cases which cannot be benefited by a judicious course
of medication and by a proper attention to hygiene. The complete
´ eradication of the disease, it must be confessed, is a result not to be
expected in the great majority of instances, even under the most fa-
vorable auspices; and only too often patients become tired of treat-
ment or discouraged long before the physician has made a thorough
trial of remedies. I have had a number of very severe cases under
my care for from ten to twelve months, and the results attained in that
time were exceedingly encouraging. One patient, in particular, I call
to mind with much satisfaction, a beautiful young lady of eighteen
or nineteen years, with a clear complexion and fresh, rosy cheeks.
The stench of her breath was something horrible. Her presence in
the course of a few minutes would infect the air of a large room.
She was morbidly sensitive regarding her infirmity, and kept herself
secluded as much as possible. Homœopathic treatment did so much
for her, that after three or four months of medication she was able to
go into society without fear of sickening those who might come into
proximity with her. At the end of a year the smell had ceased to be
obnoxious, and was only slightly noticeable for a few days after the con-
traction of a severe cold. This, it seems to me, was the best that could
be expected, and treatment was accordingly suspended. A few
months subsequently, she married a very deserving gentleman, and
has now been for several years a happy wife and mother. Her old
complaint has never returned to any annoying degree.
Treatment. The hygienic hints, regarding bathing, diet, exercise,
and dress, etc., given in the preceding sections on acute and chronic
catarrh, should be closely followed by the victims of ozæna. Every-
thing should be done to bring the general health of the patient up to
the highest standard of excellence. An abundance of outdoor exer-
cise and judicious bathing I believe to be absolutely essential to this
end. Travelling, sea-air, and sea-bathing might be recommended as
adjuncts to regular treatment, if the patient is able to enjoy these
luxuries. In treating the case of the young lady cited above, the
following remedies were employed at different times: Aurum, Kali
bichrom., Pulsatilla, and Merc. iod. I have used both the Aurum fol.
and the Aurum muriat., and of the two preparations the latter is
certainly preferable on the score of solubility. In addition to the
remedies mentioned above, the following deserve especial attention:
Arsenicum, Calcarea carb., Graphites, Hepar sulph., Hydrastis cana-
den., Mercurius viv., Nitric acid, Pulsatilla, Sanguinaria, Sepia, Silicea,
Sulphur. I have never seen any good derived from the use of Asa
DISEASES OF THE RESPIRATORY ORGANS.
123
fœtida, which has been often mentioned in connection with ozana
I
and severe catarrhal affections. In case of scrofulous individuals,
have found Calcarea, Nitric acid, Mercurius, and Sepia very appro-
priate remedies.
Where the skin of the patient is unhealthy, Arsenicum, Hepar
sulph., Rhus tox., and Sulphur, are often indicated. Close attention
should be paid to the concomitant symptoms, as they frequently
furnish the surest indications of the correct remedy. Consult the
indications given under the head of chronic catarrh.
The Spray. For the purpose of removing the foul-smelling secre-
tions from the nasal cavity, the spraying apparatus is invaluable. A
solution of Chlorate of potassium may be employed, of the strength
of one tablespoonful of the chlorate to two (2) pints of warm water.
It can be employed advantageously twice a day-say, morning and
evening. This application will disinfect the patient's breath and ren-
der it comparatively sweet, a point of very considerable importance.
both to the sufferer and to those who come in contact with him, or
her. Potassium permangan., likewise Hydrastis and Carbolic acid,
have each been strongly recommended for clearing-out and irrigating
the nasal cavity, but they possess no advantages over the simple
chlorate. As soon as the nose improves, the spray should be used but
once a day, or every other day; it is best to dispense with it altogether
if the disagreeable smell can otherwise be held in check.
SYPHILITIC AFFECTIONS OF THE NASAL CAVITY.
Years after the general symptoms of syphilis have been subdued,
a relapse may occur, affecting exclusively the nose. It is quite im-
portant to be able to determine, at an early moment, the real nature
of the trouble, as delay in proper treatment, through an error in diag-
nosis, is disastrous in its results. The first symptoms frequently
develop slowly, and are well calculated to throw both the patient and
the physician off their guard. At first the trouble is generally thought
to be of a catarrhal nature, and some time may elapse before the ap-
pearance of unequivocal indications which denote the specific nature
of the complaint.
Symptomatology.—A severe coryza may be the first symptom
which calls special attention to the nose, or there may have been for-
mation of crusts and scabs. Usually, this last condition has been
preceded by more or less malaise and discomfort about the posterior
nares and post-nasal cavity-a dryness and irritation which cause
more or less hawking and spitting.
The discharge at first is generally watery and copious; but after a
time, swelling comes on, which interferes materially with the passage
of air through the nares, and may close one or both completely. In
such cases the nasal voice is heard in perfection. In many cases
124
A SYSTEM OF MEDICINE.
plugs and scabs now form in the nose, which are removed with con-
siderable difficulty. As the disease becomes more pronounced, the
nasal symptoms change. The discharge becomes reddened with blood,
which oozes from the highly inflamed and frequently ulcerated sur-
face. Pain and external swelling rise more and more into prominence
as features of the case. The discharge becomes offensive and still
more profuse as the morbid process spreads. Finally, the bones and
cartilages of the nose are attacked, unless, meanwhile, intelligent
medical aid has succeeded in arresting the march of the horrible de-
stroyer. Fortunately, these cases are usually attended by concomitant
symptoms which render the diagnosis comparatively easy, although
I have seen a very few instances in which the specific poison seemed
to have concentrated itself for the time being upon the nose, and the
closest scrutiny failed to unearth concomitant symptoms. It is well
to remember a remark of Dr. Carl Michel to the effect that, in his
experience, ulceration of the Schneiderian membrane points unerr-
ingly to syphilis. As soon as the ulcerative process attacks the deeper
tissues of the nose, pain becomes one of the most prominent symp-
toms. It is more severe during the night than during the day, a
symptom of universal occurrence in all syphilitic conditions. The
suffering is so great that the patient begs for opiates to afford him
some rest at night. The pain of simple catarrh, involving the frontal.
sinuses, is never so intense, persistent, and deep-seated as in specific
cases.
When the syphilitic invasion of the nasal cavity is extensive, in-
volving the adjacent sinuses, the discharge is frequently retained for
a considerable time, undergoing, meanwhile, putrefactive changes
which give rise to a horrible smell. This is syphilitic ozæna.
Treatment.-It does not fall within the writer's province to enter.
into a discussion of the treatment of syphilis. No matter in what
portion of the body symptoms of the disease manifest themselves,
they must be promptly met by judicious and patient constitutional
treatment. It may not be out of place to remark that Aurum, Nitric
acid, Mercurius, and the Iodide of potassium are the most efficacious
remedies in the treatment of syphilitic affections of the nasal cavity.
When the discharge is very offensive, or when positive ozæna exists,
the parts affected should be kept as clean as possible by means of the
spray and the post-nasal syringe, used once or twice a day. The
patient should be taught to perform this sanitary office for himself,
and, both for his own comfort and for the comfort of those about him,
it should be done most thoroughly.
HAY FEVER, OR ROSE COLD.
Synonyms. Catarrhus æstivus, Hay cold, Peach cold, Yearly
cold; Hay asthma; (German) Früh-Sommer Katarrh.
DISEASES OF THE RESPIRATORY ORGANS.
125
Definition. A catarrhal affection of the eyes and of the mucous
membrane of the respiratory tract, attended, frequently, by asthmatic.
paroxysms and more or less fever, which attacks numbers of people
in the latter part of spring or in the summer, and which seems to be
caused by the volatile emanations from certain grasses, plants, and
shrubs, particularly during the season of flowering. It is peculiar in
its return every year at almost precisely the same time, varying in
individual cases; and it appears to attack more readily those who
enjoy exemption from catarrhal troubles during winter. The disease
depends evidently upon idiosyncrasy.
History. No mention is made of hay fever until the beginning of
the present century. At that time Heberden made some remarks
which show that he had recognized the affection as distinct from the
usual catarrhal and asthmatic troubles, and unique in its annual recur-
rence; but he ventured no opinion concerning the causes which pro-
duce it. Some years later, in 1819, Dr. Bostick, of England, described
the disorder at considerable length, giving attention to the special
symptoms which distinguish it from similar complaints. He called it
catarrhus æstivus, or summer catarrh; and being himself a sufferer from
it, his statements possess the advantage of remarkable minuteness and
accuracy. Other investigators speedily turned their attention to this.
field of research, and summer catarrh was henceforth regarded as a
disorder distinct in its origin and manifestations from analogous affec-
tions.
Etiology. Notwithstanding the fact that the great mass of the
population are alike exposed to the peculiar conditions which produce
hay fever, only a remarkably small number of persons are affected.
Hence it is inferred that a peculiar sensitiveness to the active cause
and a predisposition to a development of the disease are necessary
ætiological factors. It has been stated that persons of the nervous and
sanguine temperaments are more frequently attacked than others.
The effect of hereditary tendency is frequently seen, and the children
of persons who are subject to this complaint, are themselves very likely
to be affected. Symptoms of the affection sometimes occur in child-
hood and youth; again they do not appear until adult life has been
reached. Many observers have noted the fact that the poor are less
likely to be affected than the well-to-do. Dr. Elliottson, of England,
speaks of hay fever as an aristocratic disease.
The exciting cause of the affection seems to lie in the emanations or
effluvia from certain grasses, shrubs, and flowers, especially at the
season of the blossoming. The popular terms, "hay fever" and "hay
asthma," show that many persons experience an attack at the hay-
making season, which occurs about the time the grasses are in flower.
Roses, lilacs, lilies, and some other flowers, are credited with strongly
affecting many people who suffer with summer catarrh.
126
A SYSTEM OF MEDICINE.
Symptomatology.—An attack of summer catarrh is, generally,
ushered in by feelings of languor and weakness, coupled with de-
rangement of the digestive functions. Presently, disagreeable sensations
appear in the throat, eyes, and nose, with sneezing and a discharge of
watery fluid. The eyes and nose are the parts earliest affected; occa-
sionally, the symptoms seem even to be confined to them. Very fre-
quently, however, the larynx is invaded, and ultimately the bronchial
tubes become affected. At times the chest symptoms are more prom-
inent than those which attend the morbific influence on the upper
air-passages. If such is the case, asthma is generally the result. The
irritation and congestion in the lungs may be so violent that hæmor-
rhage is produced, which may result seriously in persons otherwise.
predisposed to affections of the lungs. Sometimes the larynx is
prominently affected, producing tickling in the throat, hoarseness, and
cough. If the nose and eyes are chiefly involved, the lachrymation
and fluent coryza are often astonishingly severe. The ordinary hand-
kerchief is of little utility in cases of these deluging defluxions; a
large towel is saturated in a very short time. The discharge at first is
very watery and acrid, excoriating the cheeks, the alæ of the nose, and
the upper lip, with which parts it frequently comes in contact. Later,
the secretion becomes thicker and more like the mucus discharged under
the influence of a common cold. Constant and violent sneezing is one
of the most distressing symptoms from which the patient suffers.
Paroxysm follows paroxysm, alternating with itching and burning
in the nasal cavity, sometimes confined to a very circumscribed
space.
The time when the affection prevails varies with the latitude of the
place. People of southern climates are affected much earlier than those
of the north. In the southern portion of the United States the attacks
usually appear during the month of April; in the north they are most
likely to occur during May and June. Not infrequently, in the
Northern States, according to Dr. Morrill Wyman, the summer catarrh
appears in August and continues into the latter part of September
or October. This type, which Dr. Wyman calls catarrhus autumnalis,
seems never to persist beyond the appearance of a black frost.
The duration of an attack varies according to place and individual
peculiarity, from four weeks to three months, or even longer in ex-
treme cases. In the young and robust it continues longer and rages
with more severity than in the old. Persons who have pulmonary
weakness or bronchial affections, however, are apt to experience with
advancing age an increase in the acuteness of the symptoms rather
than an amelioration.
Diagnosis and Prognosis.-Hay fever may be mistaken for cold.
in the head, influenza, ophthalmia, asthma and bronchitis, according
to the prominence and severity of certain symptoms. In differentiat-
DISEASES OF THE RESPIRATORY ORGANS.
127
ing between them, we are to bear in mind that hay fever is of yearly
recurrence, that it comes with the season of flowering grasses, shrubs
and plants, that it is of long duration and great persistency, that it
occurs in persons of peculiar susceptibility, and that its visitations are
out of the season of ordinary colds, catarrhs, and influenzas. The
prognosis is favorable to ultimate recovery; no matter how severe the
case may be, the symptoms finally disappear in all but rare cases, and
the patient recovers health and courage during the months of perfect
immunity. The existence of great debility, of pulmonary or bronchial
affections, and of other, and grave, constitutional difficulties modifies
the prognosis.
Preventive Treatment.-It is claimed by a number of ob-
servers, especially by Dr. George Moore, of England, that the system
may be fortified against an attack by especial care in diet, bathing,
sleep, etc.; in short, by a regimen which will bring the bodily powers
up to their strongest tension of resistance. If an attack of the disease
is not actually prevented, a modification of the severity of the symp-
toms is said to result. The writer's success with preventive treatment
has not been very encouraging. However, only good can result to the
patient by the adoption of any means which have the effect of im-
proving the bodily health and strength. Instruction to get beyond
the reach of the exciting causes must always be forced upon the atten-
tion of the sufferer. If the patient dwell in the rural regions, a so-
journ in a large city, selecting a quarter as remote from vegetation as
possible, or a trip to the sea-side, or a sea voyage, or an extended trip
on the great lakes, or a visit to some mountain region, almost to any
point a thousand feet above the level of the sea, may be urged with
great promise of at least temporary relief. Persons who suffer severely
in one region of country, may derive great benefit from a change of
residence; the proper locality can only be determined by making the
actual experiment. If a change of residence is impracticable, perfect
quiet in a cool room during the heat of the day, with such remoteness
from hay fields and flower gardens as can be secured, is the next best
thing.
Curative Treatment.-Arsenicum.-The discharge is thin and acrid; eyes
red, watery, and smarting; breath short from asthmatic trouble. The lower prepara-
tions are recommended.
Arsenicum iod. is said to act more beneficially than the Arsenicum album
when the acridity of the nasal secretion is very pronounced.
Euphrasia.- Applicable when the eyes are particularly affected; photophobia
and profuse lachrymation.
Ipecac.-In hay asthma; the chest symptoms are most prominent.
Kali chloricum.-In gouty and hæmorrhoidal subjects.
Kali hydriodicum.—According to Hughes, this remedy is pointedly homœo-
pathic to cases of summer catarrh in which the eyes and nose are prominently af
fected.
Sticta has been pronounced an almost specific when the larynx or bronchial tubes.
are prominently affected, and when there is much cough.
128
A SYSTEM OF MEDICINE.
Sabadilla.-Great irritation and itching of the Schneiderian membrane, with
violent paroxysms of sneezing
Quinia.—The use of an injection or spray into the nostrils, three or four times
each day, of a solution of quinine in water, one grain to the ounce, has been highly
recommended. This lotion is said to check the discharge and to lessen the violence
of the spasmodic symptoms.
In 1869 it was announced that Prof. Helmholtz, who was himself a sufferer from hay
fever, had discovered in the nasal mucus at the period of his attacks certain lively
vibrion-like organisms whose motion was quieted by the local use of quinine.
Consult also Arum triph., Euphorbium, Grindelia rob., Lobelia infl.,
Moschus.
Synonyms.
EPISTAXIS.
Hæmorrhinia, Hæmorrhinorrhagia, Rhinorrhagia,
Sanguinis naribus, Bleeding at the nose, Nosebleed; (French) Hemor-
rhagie nasale, Saignement du nez; (German) Nasébluten; (Italian)
Sanguinare dal naso.
Definition. The word Epistaxis (from the Greek ent and raw, I
flow by drops) is applied to any discharge of blood from the pituitary
membrane, whether such discharge be guttatim (by drops) or in a con-
tinuous stream. This is the most frequent of all varieties of hæmor-
rhage, and occurs in both sexes and at all ages.
History. The phenomen of bleeding from the nose, in its relation
to health and disease, was carefully observed and commented upon.
by Hippocrates, the father of medicine. He has left a number of
aphorisms which bear on this subject, especially with reference to his
theory of so-called critical discharges and critical days.
To the medical practitioners of past generations, hæmorrhage from
the nose seems to have been of far more significance than to physicians
of the present day. We cannot doubt that in earlier times epistaxis
was far more prevalent than it now is. The habitual practice of phle-
botomy, in almost every case of disease, must have powerfully stimu-
lated the blood-forming functions in those subjected to this form of
heroic treatment, until a general tendency to plethora became one of
the striking characteristics of past generations; and where plethora
exists, epistaxis is likely to occur.
Medical literature contains some notable references to this species of
hæmorrhage. Perhaps the most remarkable is found in the writings
of Morgagni, who states that in the year 1200 there was experienced an
epidemic of epistaxis in Etruria, which carried off a large number of
people in the course of a few days, an attack generally being fatal
within twenty-four hours.
Etiology.-Violent exercise; sudden changes of temperature,
especially from cold to warm; variations in atmospheric pressure ;
hot drinks; a stimulating diet; suppressed discharges; irritation of
the Schneiderian membrane from coryza; polypi; febrile complaints;
diseases of the heart, kidneys and liver, may be mentioned as causes
of epistaxis. In some persons there exists either casually or habitu-
ally an extraordinary delicacy of the nasal mucous membrane, which
DISEASES OF THE RESPIRATORY ORGANS.
129
renders its vessels peculiarly liable to laceration. A vigorous blowing
of the nose in such subjects will frequently bring about copious bleed-
ing. It must be remembered that the pituitary membrane is densely
crowded with blood vessels, and that their support and protection are
very slight indeed. The hot stage of intermittent fever is, very often,
accompanied by hæmorrhage from the nose; and typhoid fever, in its
various stages, is frequently characterized by the same symptom.
Varieties. There are two forms of epistaxis, the idiopathic and
the symptomatic. The first is sometimes termed entonic or active,
and the latter, in contradistinction, atonic or passive. An epistaxis is
termed idiopathic when no change can be discovered in the tissues of
the affected part or in any remote organs. The young and robust are
subject to this species of hæmorrhage. The blood is arterial, and its
loss is frequently salutary, this being nature's method of relieving
pressure in the cerebral system. The bleeding in this instance usually
ceases promptly when the equilibrium of the circulation is restored,
and medical treatment is seldom required. Symptomatic, or atonic,
epistaxis is observed in low and cachectic conditions of the system.
It is associated with, and dependent upon, changes in some one or
more of the great organs of the body-as, for instance, the heart, liver,
or kidneys. The blood in these cases is usually venous, and its ex-
halation is passive. In advanced life the appearance of epistaxis in
persons who have previously been free from it may be considered salu-
tary, yet denoting a threatening condition of the system. It is, often,
the forerunner of cerebral impairment resulting in palsies, apoplexies,
and epilepsies. Hepatic disorders, with jaundice, are often accompa-
nied by epistaxis of the most inveterate sort. In the entonic or active.
hæmorrhage from the nose the extreme vessels are ruptured by the
increased pressure and activity of the circulation, while in the atonic
form there is a giving way of the walls of the capillaries from debility.
Owing to their greater activity of life and the exposure incident to
the same, males are more subject to epistaxis than females. Women
are, frequently, subject to epistaxis which depends upon a suppression
of the menstrual flux. The hæmorrhage from the nose, in these cases,
appears periodically, and is usually attended with the general symp-
toms noticeable at the menstrual period.
It has been observed that the condition of the atmosphere has a
powerful influence upon the expansibility of the blood. Suddenly
entering a warm room from the cold air will often bring on hæmor-
rhage from the nose. A reduction of atmospheric pressure is even
more potent than heat in predisposing to hæmorrhage.
Mountain climbers and aëronauts are subject to epistaxis which, if
they continue to ascend, is followed by bleeding from the eyes, ears,
and lungs, attended by other distressing symptoms.
In the advanced stage of small-pox, scarlatina, typhoid fever, and
VOL. I.-9
130
A SYSTEM OF MEDICINE.
yellow fever, passive epistaxis often takes place, and must always be
considered as a symptom of grave import. It is sometimes critical,
marking the advent of improvement in the case, but oftener the fore-
runner of speedy dissolution.
Epistaxis is hereditary in some families, and is then found in con-
nection with the so-called hæmorrhagic diathesis.
Symptomatology.-Nosebleed generally takes place from one
nostril at a time. The quantity of blood lost varies from a few drops to
several pounds; an instance is recorded where twelve pounds escaped
in less than three days. The duration is variable, ranging from a few
seconds to many hours. The loss of blood from injury to the nose is
not likely to be very great, unless a vessel of considerable size is freely
opened. Coagula sometimes form in the nose and protrude from the
nostril. If the bleeding is very free, the naso-pharyngeal space may
be filled, and blood be discharged from the pharynx and from the
unaffected nostril. Occasionally, a hæmorrhage occurs at night, a part
of the blood passing into the throat and, being coughed up in the
morning, causes much anxiety by creating the impression that there
has been a bleeding of the lungs.
Many persons experience premonitory symptoms of an epistaxis.
These symptoms consist of heaviness and pressure about the head,
redness of the cheeks, and a fulness and itching sensation about the
nose.
If the hæmorrhage continue for some time, and the flow be rapid,
symptoms of faintness may appear, with roaring in the ears, weak
pulse, sighing respiration, and pallor of the face. A fainting fit during
a free epistaxis is somewhat dangerous, from the fact that the blood
may pass through the posterior nares and, flowing down the trachea,
produce asphyxia.
Diagnosis. The recognition of an epistaxis is, usually, an easy
matter; still, when hæmorrhage of the lungs or stomach exists, blood
may sometimes be vomited up and discharged through the nose. So,
too, a hæmorrhage in the post-nasal cavity may cause a discharge of
blood from the nostrils. An examination of the throat will, generally,
clear up all doubts concerning the source of the bleeding. It is, how-
ever, necessary to take careful cognizance of all the concomitant symp-
toms.
Prognosis. The great majority of cases of epistaxis have a favor-
able termination and require no treatment. Life is rarely endangered
through loss of blood on any one occasion, but a frequent repetition of
the hæmorrhage, even if the quantity of blood lost at one time be com-
paratively insignificant, may result in an anæmic condition, consti-
tuting a source of danger to the welfare, and even life, of the patient.
As already stated, epistaxis frequently occurs in the last stages of
DISEASES OF THE RESPIRATORY ORGANS.
131
low forms of disease, and, in such cases, may prove sufficiently ex-
hausting to lead to a fatal termination of the case.
Treatment.—Aconite.-In plethoric subjects; prolonged and violent arterial
hæmorrhage, with more or less fever; great restlessness, and, frequently, fear of death;
pulsation of the arteries of the neck and temples, and general fulness about the vessels
of the head; hæmorrhage caused by a fit of passion.
Arnica.- Bleeding is caused by a blow upon, or an injury to, the nose; also, after
great physical exertion; the hæmorrhage is preceded by itching in the nose.
Belladonna.-Free nasal hæmorrhage; great cerebral congestion; bleeding
at night, which awakens the patient from sleep; epistaxis from being overheated or
exposed to the sun; worse from motion; ringing in the ears; fainting.
Bryonia.—Bleeding comes on in the morning, after rising; vicarious menstrua-
tion; or bleeding from being overheated in sultry weather; irritable disposition.
China.—In the anæmic state; also, at the conclusion of a hæmorrhage, if the pa-
tient be very weak.
Ferrum.-Excellent in epistaxis occurring in debilitated subjects when there
is great pallor of the face.
Hamamelis.-Useful in the hæmorrhagic diathesis; dark, venous blood; epis-
taxis in combination with hemoptysis; venous hæmorrhage from suppressed men-
struation.
Ipecac. Nausea and vomiting; coryza, with stoppage of the nose; quick, anx-
ions breathing, with suffocative attacks; pale face, with blue margin around the eyes.
Nux Vomica.-Constipation, or suppressed hæmorrhoidal flow; pain in the
forehead; after drinking wine; in the case of habitual drunkards.
Phosphorus.-Profuse bleeding, recurring frequently; ecchymoses on the
body; hæmorrhagic diathesis; bleeding, especially when at stool.
Pulsatilla.-Discharge of blood every afternoon or evening, especially in case
of women who have suppressed or scanty menstruation.
Secale.-Splendid in anæmic cases, whether from exhaustive depletion, or from
long-continued diseases; blueness of the skin.
Accessory Measures.-Application of cold water to the nose
and forehead and back of the neck is classical in its antiquity. The
patient should be kept perfectly quiet if the bleeding is considerable.
Much benefit may be derived from firm pressure of the ala of the affected
side upon the septum, thus closing the nostril and the anterior portion
of the cavity, the object being to bring about coagulation of the blood,
and occlusion of the open vessels. The sitting posture, with the head
bent slightly forward, is to be recommended. The clothing should be
loosened about the throat, so as not to interfere with the return of the
blood from the head. A pledget of lint, or charpie, fastened together
with a thread, may be used as a tampon for the anterior portion of
the nasal cavity. This should be removed as soon as it becomes of
fensive, usually at the end of twenty-four hours. Authors recommend
the use of astringents, as tannin, chloride of zinc, nitrate of silver, al-
cohol, vinegar, solutions of the chloride of iron, etc. These, properly
diluted, may be injected into the cavity, or the tampon may be satu-
rated with the same. Snuffing powdered Matico-leaf into the nostril
frequently stops bleeding. Dr. Negrier recommends that one or both
arms be raised above the head, and held in that position for some
length of time; he states that this simple procedure seldom fails to
132
A SYSTEM OF MEDICINE.
arrest an epistaxis. Plugging the posterior nares has been recom-
mended, and an instrument, called Bellocq's canula, has been designed.
to facilitate the operation. A description of the method of procedure.
will be found in any work on surgery. Should the patient faint from
exhaustion, turn him on his face, so that the blood will not run back-
ward into the throat and produce asphyxia.
Resuscitation can, generally, be brought about promptly by a weak
stimulant, such as a little camphor, or a few teaspoonfuls of brandy.
TUMORS OF THE NASAL CAVITY.
The term polypus is usually, though inaccurately, applied to every
tumor existing in the nasal cavity. Whether the method of attach-
ment of the majority of these tumors or their color led to the adoption
of the name of the zoophyte polypus, after which they are called, is a
mooted point. We shall confine our remarks here to polypoid growths
proper; a consideration of other benign and malignant tumors which
sometimes infest the nasal cavities falls properly within the domain of
surgery.
Etiology. It is generally believed that nasal polypi originate.
upon a mucous membrane weakened or altered by chronic catarrh.
Persons of a strumous or sycotic diathesis are most frequently afflicted
with these growths.
Varieties.-There are several kinds of these tumors found in the
nasal cavities. The most common are the mucous and the fibrous.
The former are the more frequent. They are very soft and vascular,
sometimes of almost gelatinous consistency. They bleed frequently,
and possess the attribute of absorbing moisture from the atmosphere,
thus increasing in size. They seldom exist singly, but generally infect
both nostrils, from three to ten being sometimes found in each passage.
They differ greatly in size, and are usually of a pinkish color, shaped
like a pear, and attached by a pedicle to the mucous membrane of the
cavity. The middle turbinated bone is a favorite seat for these growths,
which are seldom found attached to the roof of the nasal cavity or to
the wall of the septum.
The fibrous polypi are much lighter in color, and much firmer and
more elastic in structure than the mucous variety. They also are
pear-shaped and attached by a pedicle. They do not often bleed, nor
do they absorb moisture from the atmosphere. They usually appear
singly, and are ordinarily of slower growth than the first-mentioned
variety.
Symptoms. There is usually a yellow mucous discharge from the
nose and the pharyngeal vault. Stenosis of one or both nostrils, com-
pelling the patient to breathe through the mouth, and producing the
well-known nasal speech, is a pretty constant symptom. Occasionally,
when the passages are wide and capacious, tumors may exist for some
DISEASES OF THE RESPIRATORY ORGANS.
133
time in the cavities without shutting off the current of air. Tumors
which possess the quality of absorbing moisture in damp weather
necessarily increase the obstruction.
If tumors exist at the posterior nares, and drop back into the
pharyngeal cavity, the patient may inspire air through the nose
without being able to expel it by that channel-the tumors acting as
a valve, and closing the passages. Bleeding from the nose is frequently
observed. The blood may come from the highly vascular tumor itself,
or from the adjacent mucous membrane, which is congested and irri-
tated by pressure of the morbid growth. In emaciated persons the
discharge of mucus is very slight. Some patients complain of frontal
headache and vertigo, while others aver that the existence of the
growths in the nose is responsible for a certain amount of intellectual
impairment. The tumors themselves seem to arise without pain, and
may grow to very considerable size before the patient's attention is
called to their existence. The disturbances experienced are frequently
attributed to the existence of simple catarrh.
Diagnosis. Inspection of the nasal cavities with a good light and
with the use of speculum and probe will, generally, enable the prac-
titioner to detect the existence of these morbid growths.
Polypi in some cases are of the color of the adjacent mucous mem-
brane; in others, they are more transparent, and of lighter color.
When a polypus is attached to the posterior portion of the cavity, it
may be brought forward by forcibly blowing through the affected
nostril; this method is particularly successful if the growth be pedun-
culated. When both nostrils are closed by polypi, the sufferer is
compelled to breathe through the mouth, and, usually, a peculiar
rattling is noticeable; this symptom is diagnostic.
Treatment.-Cases of polypus narium have been frequently re-
ported cured by the use of internal remedies. The remedies which
seem to have been most successful are Calcarea, Phosphorus, Staphi-
sagria, Teucrium, Sepia, Silicea, Sanguinaria, and Thuja. Jahr has
been most successful with Calcarea and Sanguinaria; he speaks slight-
ingly of Teucrium. Fibrous polypi, he thinks, fall especially within
the province of Calcarea, aided by a preparatory course of Sulphur.
Where polypi bleed easily, he believes the proper remedy to be Phos-
phorus. Dr. Richard Hughes refers to several cases cured by the use
of Calcarea and Teucrium, and he gives to Thuja a more than passing
notice. We possess considerable evidence confirming the therapeutic
value of Teucrium, used both internally and as a topical application.
In numerous instances surgical aid had been repeatedly invoked, but
the growths returned until finally and permanently cured by the ad-
ministration of this remedy.
Sanguinaria, used internally and locally, is credited with the cure
134
A SYSTEM OF MEDICINE.
of numerous cases of polypi since its mention by Jahr. Calcarea
phosphor. has also been given with fair success in a number of cases.
Accessory Measures.-Where nasal polypi refuse to yield to
internal medication, they may be removed by the galvano-cautery.
A loop of platinum wire is passed around the pedicle of the polypus,
and is then raised to a white heat by the passage through it of a cur-
rent of electricity. By this method hæmorrhage seldom occurs, as the
vessels are occluded as soon as they are severed. The galvano-puncture
is also employed in the removal of tumors of the nasal cavity. The
chemical action of electricity is made use of in this method to destroy
the vitality of the morbid growth and to stimulate its rapid absorp-
tion. The operation is not at all difficult, consisting in the passage of
a gold or silver needle into the body of the polypus, attaching said
needle to one of the poles of a battery, while the other pole is held in
contact with the skin near the seat of the tumor. A single-cell battery
is sufficient for small tumors, and an average of six sittings is required
for the removal of the ordinary mucous polypus. Full directions for
the use of the galvano-cautery and the galvano-puncture may be found
in the latest works on special surgery of the larynx and nasal cavity.
ABSCESS OF THE NASAL CAVITY.
The anterior portion of the nasal cavity, near the nostril, is often
the seat of circumscribed inflammation which ends in an abscess.
These furuncles generally attack one nasal passage at a time, and,
though comparatively insignificant, are apt to cause a very considerable
amount of pain and disturbance. They are sometimes attended by
pronounced fever and, now and then, by brain symptoms. Frequently
a sort of habit seems to exist tending to the production of abscesses
in the nose; and no sooner does one furuncle disappear from the
affected nostril before another appears on the opposite side, to con-
tinue in alternation for an indefinite period of time.
An abscess in the nasal cavity usually matures rapidly, and, as soon
as the products of inflammation are discharged, either spontaneously
or through surgical aid, the pain and oedema disappear.
Treatment.-Remedies which are homoeopathic to boils in other
parts of the body are generally applicable here. An effort should be
made to destroy the tendency to a recurrence of these annoyances.
The classical course of Sulphur may be all that is required to consum-
mate this end. During the active stage of the abscess recourse may
be had to one of the following remedies, which should be selected to
meet the individual condition: Arsenicum, Arnica, Belladonna, Hepar
sulphur., Calcarea, Nitric acid, Nux vomica, Mercurius, Phosphorus,
Phytolacca, Sulphur.
Accessory Measures.-If the pain and oedema are very great,
palliation may generally be obtained by the application of a hot com-
press, or by the inhalation of vapor of water.
DISEASES OF THE RESPIRATORY ORGANS.
135
The writer has seen great benefit arise from the use of a pledget of
cotton or wool, saturated with olive oil, and passed into the affected
nostril, so as to keep the inflamed surface thoroughly moistened with
the oil. The pledget may be introduced at night and allowed to re-
main until morning. It need exert only sufficient pressure to keep it
in place at the vestibule of the nasal passage.
FOREIGN BODIES IN THE NASAL CAVITY.
It very frequently happens, especially in case of young children,
that foreign bodies, either by accident or design, are forced into the
nasal passages. A list of articles actually reported as having been
removed from the nose would present an astonishing variety. Grains
of corn, pumpkin and melon seeds, beans and peas, glass beads, mar-
bles and pebbles, seem to be most in favor with the little people.
Cases have been reported in which the seeds and grains which have
found a lodgment in the nose have germinated, producing sprouts of
considerable length. The inflammation produced in the nose by the
pressure of a foreign body is frequently very pronounced, and chronic
rhinitis, with ozæna, may result from it. Threatening brain symptoms
have been known to originate under such circumstances, which were
promptly relieved by the removal of the foreign substance. The
presence of foreign bodies in the nose gives rise to symptoms which
closely simulate ordinary catarrh and ozæna. Examination of the
nasal cavity by means of the speculum and the probe will generally
determine the diagnosis of these cases. The offending substance is
usually found covered with a secretion which must be removed before
the nature of the body can be determined. A portion of denuded
bone is about the only thing which could be mistaken for a foreign
body in the nasal cavity.
Treatment.-Effort should be made at once to remove the intrud-
ing substance. A fit of sneezing, excited by a pinch of snuff, may
answer the purpose; if this fail, a spoon-shaped instrument or a pair
of delicate fenestrated forceps should be employed.
B. DISEASES OF THE LARYNX.
BY JOSEPH SIDNEY MITCHELL, M.D.
ACUTE CATARRHAL LARYNGITIS.
Synonyms. Simple and acute laryngitis; Cynanche laryngia;
Angina laryngia; Inflammation of larynx; (French) Catarrhe laryn-
gien; (German) Katarrhalische Kehlkopfentzündung.
Definition. It is a simple inflammation of the mucous membrane
of the larynx, sometimes involving the sub-mucous tissues, occurring
136
A SYSTEM OF MEDICINE.
idiopathically or in connection with the exanthems, or during chronic
laryngitis, being grafted upon it, usually terminating in resolution, but
occasionally causing severe or even fatal œdema glottidis.
Ætiology.—The predisposing causes are sedentary, indoors life,
and previous inflammation of the larynx. Males are more prone to it
than females, and adults more than children. The greatest fatality
occurs in youth. Four-fifths of all the mortality from acute laryngitis
occurs in children before the tenth year.
Exciting Causes.-These are exposure to cold, especially cold
and dampness applied to the back, neck and feet. Direct irritants, as
dust, fumes of acids, vapors of iodine, bromine and chlorine; chemi-
cals, as alcohol, spices, tobacco; swallowing hot water or caustic solu-
tions. Mechanical irritants; shouting by sailors, military men, and
others in command. State of the atmosphere; undoubtedly there are
certain atmospheric conditions obtaining in the spring and fall which
specially induce attacks of this form of catarrh. When an epidemic
of influenza is prevalent, there is some unknown specific exciting
cause. Why the laryngeal mucous membrane should be selected dur-
ing one epidemic is a mystery. At the present time there is an epi-
demic of influenza raging in Chicago which has a special predilection
for the larynx. Scarcely a case attacked fails to present the charac-
teristic symptoms, in greater or less degree, of this affection. No in-
considerable number of cases occur from the use of too strong local
applications. The laryngeal mucous membrane is richly endowed.
with sensitive nerves, and should be treated gently. It seems to be the
idea of some laryngoscopists that strong applications can be made
with impunity.
Pathology. In mild cases we have a fiery red appearance of the
whole mucous membrane, or the congestion may be confined to the
epiglottis, ary-epiglottic folds, ventricular bands, inter-arytenoid space.
and the arytenoids, and particularly the posterior ends of the vocal
cords. The vocal cords may be affected, though more rarely. Some-
times there are spots of ecchymosis. The rosy hue may not be seen
after death, because the laryngeal mucous membrane is rich in
elastic fibres, and the blood may be pressed out by their contraction.
If there is no swelling of the mucous membrane, there is no impedi-
ment to deglutition or respiration, but we may have pain, hoarse voice,
and hoarse cough. Infiltration may involve the mucous membrane,
particularly in the congested regions, and it accordingly increases in
volume, is moister and more flabby. It may affect the glottis and
cause dyspnoea. If the sub-mucous tissue is involved we have greater
swelling and oedema glottidis more marked, which condition we shall
later consider. The ephithelium is altered, the cells are not all well
formed, and there is partial destruction, all these low forms stopping
short, however, of ulceration. The secretion is changed. At first it is
DISEASES OF THE RESPIRATORY ORGANS.
137
clear and sticky, then tenacious, later muco-purulent, and, may be,
purulent. Abscesses may occur during the stage of acute inflamma-
tion, but they are rare.
Symptoms. An attack usually begins with rigors, slight or quite
pronounced, followed by a distinct febrile movement. The patient
then complains of sore throat, feeling of soreness in the larynx, burn-
ing, tickling, sensation of constriction as of a foreign body present.
Speaking or coughing is at times very painful. In one instance, under
my observation, of severe acute laryngitis in an adult, the pain was so
intense on coughing that he felt as though one more paroxysm would
kill him. Sensitiveness to external pressure is often present, though
not always. The cough is hoarse, barking, and generally occurs in
severe paroxysms, though in some exceptional instances it is only
moderate. If the vocal cords are thickened, bulge forward, and are
thrown into strong tension, we have the sound of a bark. The voice
is hoarse, deep, cracked, and there may be complete aphonia. Two
patients lately treated presented the latter symptom with laryngeal
catarrh of slight degree. This symptom may be due to the swelling
of the vocal cords, thus preventing vibrations, or to a swelling of the
ventricular bands which press upon the vocal cords and thus inter-
fere with their tension. Cracking of the voice is due to approximation.
of the swollen vocal cords covered at points with mucus.
The ex-
pectoration is scanty at first, only, we presume, because the amount of
mucous membrane involved is small. It is about the same in quan-
tity according to the surface affected as in other inflammations of the
mucous membrane. In the early stage it is clear and glassy; later,
from mingling of epithelial cells and mucous corpuscles, thicker and
more turbid; still later, as pus-cells are more abundant, it is yellow
and purulent. If there is considerable swelling of the mucous mem-
brane, dyspnoea may exist, and, if the sub-mucous tissue is much in-
volved, it may become urgent, and threaten suffocation,
Course and Termination.-It lasts from several hours to five
days, generally terminating in recovery, rarely going on to oedema in-
ducing collapse and death. There is a form of sub-acute laryngitis
with congestion which merely gives rise to a slight cough and hoarse-
ness, soon passing away.
Therapeutics.—Aconite, earliest stage, particularly in children; fever, dry
skin, roughness of the throat; hoarseness, sensitiveness to air; expectoration slight,
thin and frothy; often the only remedy needed.
Belladonna.-Flushed face, aphonia, perspiration, sleeplessness, dry cough
before midnight; much vivid redness; sensation as of dust in the larynx, or of con-
striction; painful deglutition.
Hepar sulph.-Hoarse cough, rattling of mucus in the larynx, muco-purulent
secretion, dyspnoea, tickling; useful often after Spongia.
Lachesis.-Purplish mucous membrane, dry violent cough.
Phosphorus.-Dry spasmodic cough, scanty, blood-streaked expectoration, ag-
gravated by speaking.
138
A SYSTEM OF MEDICINE.
Spongia.-Congh barking, hoarse, hollow, and dry; wheezing inspiration without
expectoration or with tenacious mucus, yellow and lumpy; aggravation before midnight.
Tartar emetic.-Dyspnoea, pallor of countenance, rattling cough, accumula-
tion and rattling of mucus in the throat.
Accessory Remedies. Hyoscyamus, Ipecac., Nitric acid, Sangui-
naria canadensis, Stannum.
Prophylactics.-Bathing the throat and back of neck every morn-
ing with cold salt water freely, tends to lessen the frequency of the
attacks. Those subject to this affection should accustom themselves
to but little covering about the throat.
Adjuvants.-Inhalation of hot water with a steam-atomizer is
often very serviceable. Scarification will only need to be resorted to
in case of oedema glottidis, which will rarely occur after use of the above-
mentioned remedies.
EDEMA GLOTTIDIS.
This disease should be more accurately termed oedema laryngis. It
is an inflammation attended with marked infiltration, notably of the
arytenoids, epiglottis and the glottis, with a serous or sero-purulent
fluid. There is a form described by Dr. Green called sub-glottic, in
which the infiltration is beneath the vocal cords.
Ætiology.—It occurs during attacks of acute laryngitis and pharyn-
gitis; traumatically, from the deglutition of hot and caustic liquids.
Secondarily, it follows scarlatina, measles, typhoid fever, Bright's dis-
ease, and any disease resulting in anasarca. Also, it arises in the
chronic laryngitis of syphilis or tuberculosis and carcinoma of contig-
uous parts. Tumors of the cervical region, wounds of the throat and
neighboring parts have induced it. It is more frequent in "alcooli-
ques,” and in men than women, and generally in those of broken-down
constitutions. Its exciting causes are exposure to cold and moisture.
Pathology.—We have an inflammation of the mucous membrane
which only differs from that of acute laryngitis by a more marked
serous effusion and a less degree of hyperæmia. Inspection shows
the enlarged epiglottis projecting like a bladder. With the act of retch-
ing the ary-epiglottic folds may be seen bulging into the larynx. The
ary-epiglottic folds and ventricular bands may be swollen into one
mass, leaving only a chink for the passage of air. Palpation may
detect them. The narrow chink is rendered smaller during inspection,
as the swollen parts are thus pressed together.
Symptoms.-There is tenderness and pain on pressure, a sensation
of constriction, dyspnoea, and a whistling, stridulous sound, increasing
to impending suffocation, with great lividity of countenance. There is
cough, not always attended with expectoration, and difficulty of swal-
lowing, feebleness of voice, hoarseness, aphonia. The patient is obliged
to exercise great care during the act of respiration and also in attempt-
DISEASES OF THE RESPIRATORY ORGANS.
139
ing to swallow, as fatal results have quickly occurred during the effort
to take food. The suffocative attacks tend to recur, and in one of these
the patient may die. In the latter stages of the disease inspiration
and expiration are both affected; in the subglottic variety the breath-
ing is more stridulous.
Therapeutics.-Aconite controls the active hyperemia so often present.
Arsenicum is the remedy, par excellence, for this affection; it especially covers
the low tone of the organism which is incident, and it directly affects the cedema; it
promotes the absorption by restoration of tissue-force, and its action is generally prompt.
Apis. Not as useful in my hands in controlling œdema of the larynx as the above,
but effective when there is soreness and stinging, and when the parts are not only
puffy but glossy.
Lachesis.-Livid mucous membrane, and suffocative attacks very urgent.
Accessory Remedies.-Iodine, China, Rhus, Stramonium.
Scarification will be necessary in case there is suffocation, and fatal
collapse is impending. It may be accomplished with a curved bis-
toury, wound to within one-third of an inch of the end; guided by the
finger, it may be passed to the swollen upper portions of the larynx.
A number of incisions should be made. Some relief may be obtained
by scarifying freely the posterior wall of the pharynx. Buck has de-
vised a laryngeal knife especially adapted to this purpose. If care is
exercised, no harm can be done with the scarifier. It is, of course,
needless to say that particular attention should be paid to avoiding
the vocal cords. There is usually no great hæmorrhage; if there is,
ice and external pressure may be required.
CHRONIC LARYNGITIS.
Definition. It is a chronic inflammation of the mucous mem-
brane of the larynx, with hoarseness and cough, often spasmodic in
character.
Etiology. It rarely follows acute cases. It may arise from ex-
tension of inflammation from chronic pharyngitis. Its slow develop-
ment sometimes occurs after comparatively insignificant acute attacks.
During the course of phthisis and syphilis it is of frequent occurrence.
Symptoms. Subjective.-The most common is the hacking or
hemming induced by a desire to clear the throat. There may be
tickling, pricking, stinging or burning, and feeling of fulness and ten-
sion.
Objective Symptoms.-There is alteration of the voice, from
hoarseness to complete aphonia. The hoarseness is very apparent
after rising, and improved by the use of the voice. If the vocal cords
do not approximate well, the voice is strong when first used, and grows
weak. Tenor voices show this most prominently. The tenor robusto
will sing strongly to the end of the opera, while the feeble tenor voice
will begin to weaken long before the close.
140
A SYSTEM OF MEDICINE.
Laryngoscopic Appearances.-Hyperemia may be observed,
which may be partial or complete. The order in which the mucous
membrane in different parts of the larynx is involved by this hyperæ-
mia is 1st. The cartilages of Santorini. 2d. The ventricular bands.
3d. The epiglottis. 4th. The ary-epiglottic folds. The injection is
generally arborescent when the epiglottis is involved, and linear if the
vocal cords are implicated. One vocal cord may be bright red,
while the other is white. A mucous secretion adheres to different parts
of the larynx. In old cases the larynx may look dilated, and the
mucous membrane is bathed with considerable secretion, or it may be
dry and shining, giving us the atrophic form of catarrh. The vocal
cords may not approximate, since the thickened mucous membrane
prevents the proper action of the muscles. The nature of the expec-
toration varies with the stage. Its quantity is usually said to be small,
but probably equally extensive with that from other inflammations of
other mucous membranes. It should be remembered that there is only
a small quantity of mucous membrane involved in the inflammatory
process. In bronchial inflammations, on the contrary, a very large
mucous surface may be attacked.
Course and Termination.-The development of the disease is
usually slow, and being once established it remains permanently, or
the inflammation may subside, and another attack recur.
It is spe-
cially prone to be recurrent. Edema may set in, but this is of rare
occurrence. In many cases it is the forerunner of phthisis. Phthisis
does not result from it, that is, it is not the originator of the disease;
the laryngeal congestion is part of the tuberculous diathesis. All cases
of chronic laryngitis should be carefully watched for symptoms of
pulmonary phthisis. In a great proportion of cases of persistent or re-
current chronic laryngitis, sooner or later the history shows that phthisis
will obtain. The treatment, therefore, is of unusual interest, since
through the careful watching of the case we may be put upon the
track of the earliest manifestations of phthisical inflammation in the
lungs.
Diagnosis. The hyperemia with masses of mucus upon the mem-
brane should be carefully observed. The tumefaction generally is not
considerable. It differs from oedema glottidis, which has a bright color
and transparent appearance.
In laryngeal phthisis there is a dull or anæmic appearance and
thickening of the parts. An examination of the lungs usually enables
us to make the diagnosis.
Prognosis. This affection is not fatal in itself, but may be the ini-
tial stage of phthisis; the swelling over the capitulum Santorini is an
early sign of this disease.
Therapeutics.-The treatment for the acute grades is the same as
that already given in acute laryngitis.
DISEASES OF THE RESPIRATORY ORGANS.
141
Kopar sulph. has done so much for me that I consider it the most effective
of all remedies. Its use in cases occurring in professional singers has been attended
with such success that I do not hesitate, on taking the case, to express the belief that
not only the laryngeal inflammation will be relieved, but that a manifest improvement
will be apparent in the quality of the voice.
Causticum is of service for the paralytic weakness which sometimes remains
after the mucous membrane has been restored to its normal condition. It is not a
centric paralysis, but simply due to the irritated condition of the muscles remaining
after they had been rendered somewhat sodden by the inflammatory process.
Arsenicum, useful for nervous, irritable subjects, with burning in the larynx,
cough occurring in paroxysms, expectoration scanty, lumps of gray mucus in the
morning.
Iodine is peculiarly adapted to catarrhal subjects, and is specially indicated when
the larynx is sore in one spot, in follicular inflammation; expectoration sticky and
scanty.
Iodide of potassium.-Dryness, burning, irritation, feeling of a lump; ex-
pectoration free.
Nitric acid, in violent paroxysmal cough with rattling of mucus, difficult to
expectorate.
Sanguinaria, tough, thick, offensive blood, streaked sputa, cough at night,
abundant expectoration of white mucus, bad smelling, sometimes blood-tinged.
Tartar emetic, pallor, abundant expectoration, whitish and thick, does not
expectorate as easily as its sound would indicate.
Selenium and the Seleniate of soda are recommended by Meyhoffer in cases of
follicular laryngitis. My own experience has proved the value of these preparations.
Phosphorus, when the voice tires easily after using it; dry cough; blood-
streaked yellow expectoration from pus-corpuscles. In the catarrh of phthisical per-
sons it is exceedingly serviceable.
Local Applications.-Inhalations are useful as palliatives. Gly-
cerinated water, one part of glycerine to four of water, is excellent in
cases of atrophic catarrh characterized by lack of secretion, when the
mucous membrane is not over-susceptible to this substance.
Hot wa-
ter affords relief in the more acute grades. Chloride of potassium, 5
grains to the ounce of water, has an excellent effect as a stimulant;
also, Chloride of sodium, 5 to 20 grains to the ounce of water. Saline
inhalations exercise a tonic power over the mucous membrane. Per-
sons accustomed to bathing at the seashore can testify to the rapidity
with which the action of the sea-water cures stubborn cases of naso-
pharyngeal or pharyngeal catarrh; its effect is equally efficacious upon
the laryngeal mucous membrane. Carbolic acid, 2 grains to the ounce,
when there is a high degree of irritation with dry mucous membrane,
may prove of value.
Argentum nitricum should be used in follicular laryngitis, in a prepara-
tion of grain to one grain to the ounce of water. Iodine, a single drop in an ounce
of water, as an inhalation, and three drops to one drachm of glycerinated water to be
applied locally with a brush, is also of service in the follicular variety. The use of
local applications is not frequently required when the homoeopathic remedies are ad-
ministered internally, but their excellent palliative effect, at times, cannot be denied.
The above solutions may be inhaled from the steam atomizer for five
minutes twice daily. I believe, notwithstanding the doubt recently.
expressed, that this method will effect a saturation of the parts to the
necessary degree.
142
A SYSTEM OF MEDICINE.
PERICHONDRITIS LARYNGIS.
Definition.—An inflammation of the perichondrium of the larynx,
followed sometimes by chronic inflammation and caries of the carti-
lage.
Ætiology.—It is very rarely a primary disease, but follows usually
tuberculosis, syphilis, and typhoid fever.
Pathology. The mucous membrane is infiltrated over the affected
parts, the cartilage thickens, a grayish abscess may form, and the
whole cartilage slough. The cricoid and arytenoid cartilages are the
most frequently affected; the thyroid may also be involved.
Typhoid ulceration follows usually the inter-arytenoid fold, and the
ulceration may become rodent and thus affect the cartilage. When
an abscess forms, the pus may escape into the trachea, find its way
externally, or cause death, if confined, with same symptoms resembling
those of a fatal attack of oedema glottidis. Laryngoscopy shows in-
flammation, tumefaction, ulceration, and loss of substance. The seat
of the attack may be detected, also the seat of the abscess, if one has
formed. If the abscess involves the thyroid, it will be below the vocal
cords; if it involves the cricoids, just under; if the arytenoid, it will
be above the glottis.
Symptoms. The pain is characteristic, dull, aching in character,
at times burning or boring. There is dysphagia which may become
extreme in case of the formation of an abscess. Hoarseness, proceeding
to complete aphonia, may obtain. Dyspnoea may be present, and in
the graver pathological conditions become very serious. The forma-
tion of the abscess gives rise to the characteristic pain upon pressure,
external swelling and tenderness. The diagnosis is rendered easy, by
laryngoscopy; the enlargement of the cartilage is significant. There
may be extensive hyperæmia, or it may be very moderate, save over
the affected part. The ulcers, or abscess, if present, are apparent.
Treatment. Support the general system with milk, beef tea, or
other easily assimilated nourishment. Arsenicum meets the debili-
tated condition which is incident to the affection, and is also specially
indicated when there is burning pain, sense of soreness, and disposi-
tion to ædema.
Silicea is of service when the ulcerative process has been established.
Sulphur is indicated when there is purulent expectoration, pain on
deglutition.
Locally, Fowler's solution, 18 drops to 6 ounces of water, inhaled
four or five minutes, two or three times a day, is beneficial.
LARYNGEAL PHTHISIS.
Synonyms.-Tuberculous laryngitis; Helicosis laryngis; Phthisie
laryngie; Kehlkopftuberculose.
Definition. A chronic inflammation of the larynx with thicken-
DISEASES OF THE RESPIRATORY ORGANS.
143
ing and ulceration of the laryngeal tissues, attended with chronic
hoarseness or aphonia, dysphagia, and the symptoms of phthisis.
Etiology. The chief predisposing cause is the tubercular diathe-
sis. The view of Niemeyer and of his followers, that there is a ca-
tarrhal inflammation which gives origin to some forms of phthisis
which are not tubercular, has many adherents. At one time this
seemed satisfactory to my own mind, but experience leads me to take
a step backward, as it seems, to the old view of Laennec, which is that
all these old forms of interstitial inflammation are really the result of a
specific diathesis, and different modifications of the inflammation are
merely the results of individual tendencies influenced by hygienic sur-
roundings and other modified circumstances. All debilitating influences
hasten the outbreak. Exposure to cold acts as an exciting cause, and
so do irritants. The person with latent disposition may escape the
influence of an exciting cause, but usually does not, as the tendency
is so strong that an insignificant cause determines the attack. Hence,
whole families may succumb. Generally, the lung complication pre-
cedes, but exceptionally the laryngeal phthisis is the forerunner of the
general disease. In one instance which came under my observation,
the patient had been in former years affected with chronic laryngitis,
hoarseness, and feeble voice. Finally laryngeal phthisis supervened,
afterwards pulmonary phthisis, and death. Having had an opportu-
nity to follow this case for some twenty-five years, I was enabled to
notice the unerring sequence of events. Mackenzie has had cases of
laryngeal phthisis which did not show pulmonary trouble after careful
physical examination, but he has only been present at three autopsies of
laryngeal phthisis where no sign of pulmonary involvement was present.
Pathology. First, anæmia is early noticed, and when not de-
pendent upon any other known cause, it is particularly significant.
Second, the hyperæmia is not so extensive as in chronic laryngitis, but is
more pronounced. Third, thickenings occur usually by serous infiltra-
tion, involving the ary-epiglottic folds and ventricular bands. The in-
filtration of the epiglottis and ventricular bands is at times semi-solid.
Fourth, ulcers may form; these are at first small, but join and pro-
duce larger. The racemose glands of the under suface of the epiglottis
and ventricular bands are early involved. The processi vocalis are also
involved through mechanical irritation. The ulcers are at first of the size
of a pin-head, and may increase to that of a shilling. The worm-eaten
appearance which has been described is due to numerous pin-head
ulcers. The destruction of tissue is not often great, but the ulceration
may be rodent, attacking the muscles, fibrous tissues, and, extending to
the cartilage, form an abscess. Caries of the cartilage is more common
from laryngeal phthisis than from all other causes combined. Ac-
cording to Mackenzie, necrosis of cartilage is due to inflammation of
the perichondrium, which may be separated from the cartilage by
144
A SYSTEM OF MEDICINE.
pus. Ossification precedes necrosis, and the cartilage may be left dark
gray or black; it may be increased in size, or atrophied. The relative
infrequency of graver pathological lesions under homœopathic treat-
ment cannot be too strongly insisted upon; that many of these lesions
are due to the destructive influence of tissue-destroying drugs, like
Mercury and Iodide of potassium, seems probable. Rarely do we
encounter in our cases the gravest phenomena so often referred to by
classic writers. Only once in twenty years' experience in private hos-
pital and dispensary practice have I had a patient suffering with
severe dysphagia during the existence of laryngeal phthisis. The
presence of true tubercle is rare. Rokitansky states that it is deposited.
in the form of gray granules in the sub-mucous areolar tissue, or infil-
trated as yellow caseous matter beneath the mucous membrane,
usually over the arytenoid muscles and arytenoid cartilages. Louis
did not consider that tubercle was deposited in laryngeal phthisis, but
found ulceration in one-fourth of the cases examined. Mackenzie has
never seen the gray granules referred to by Rokitansky, but thinks the
deposits consist of serous fluid, etc., and a few compound granule cells
with molecular and granular matter. Meyhoffer says the secretion of
pus takes place after the epithelium is destroyed; denuded patches
appear, studded with small granules, out of which pus oozes freely.
These granules are only mucous follicles, but these follicles are the
seat of destructive inflammation. The ducts are not obstructed as in
follicular inflammation, but are dilated and yield pus freely on pressure.
Before long, complete destruction is the result of this diathetic inflam-
mation. A deep cup-shaped ulceration is formed, which extends to
the deeper structures of the mucous lining, and soon involves the sub-
jacent and adjacent parts in the same destructive process, leaving
nothing but one deep ulceration filled with pus. This seems the clearest
statement of the origin and course of the ulceration with its pathologi-
cal features.
Laryngoscopic Appearances. In addition to what may obvi-
ously be seen, as just described, it should be again noted that the anæmia
is characteristic; this anæmic appearance is also observed in the pharynx.
Large, pale pyriform tumors formed by oedematous swelling of the ary-
epiglottic folds and interarytenoid folds are observed. Sometimes only
one side is affected. The cartilages of Santorini and Wrisberg may
interfere, at first, with the pyriform shape, but later are involved in the
general swelling. The diagnosis of the disease may certainly be made
when these are seen. Mackenzie says, when these tumors are once
established, this disease is as certain to terminate fatally as a case of
tubercles or of encephaloid cancer. The epiglottis is often thickened,
and its turban-shape is characteristic. Its enlargement may prevent
the inspection of the parts below, and it may be rolled back upon
DISEASES OF THE RESPIRATORY ORGANS.
145
itself. The ulceration noted may be distinctly seen, unless some ob
struction to the laryngeal image exists.
Symptoms. The subjective symptoms of chronic laryngitis are
generally present; burning, smarting, or sensitiveness to pressure.
There is hyperæsthesia both of larynx and pharynx. It is usually ex-
treme, but there are wide differences which may be noticed. Some
cases of phthisis laryngis are easily examined. Others present such á
high degree of hyperesthesia that the operation is difficult, even after
the use of remedies to control this symptom. Any one who has had
experience in laryngoscopy will readily recognize the difficulty in some
instances of securing a good inspection of the larynx, owing to the
rapid gagging which at once occurs on the first effort to introduce the
mirror into the fauces. Dysphagia is a later symptom, and is sometimes
marked. Ordinarily, as above noted, we are able to control this symp
tom by the use of our remedies. When present, it is due to a thicken-
ing of the epiglottis, but may exist when the ary-epiglottic folds or
interarytenoid folds are affected. There are cases where the dysphagia
is so extreme that the patient would die of starvation rather than eat,
unless the suffering is relieved by a strong application of morphia.
Objective Symptoms.-Hoarseness is one of the most prominent
symptoms; when it develops in a case of pulmonary tuberculosis and
continues for some little time, we may at once suspect the existence of
laryngeal phthisis. If the lesion existed only on the posterior wall of
the larynx, there might be no hoarseness, but this implication, with no
other part affected, is rare. Aphonia comes still later and varies in
degree. It is due to structural lesion, or may result from functional
causes. The cough may be tickling, dry, violent or spasmodic in the
advanced stages; Trousseau termed it a belching cough. Patients with
laryngeal phthisis vary very much as regards the amount of cough,
according to their physical sensitiveness. The expectoration has no
special characteristic. It is generally muco-purulent; sometimes
scanty, at other times quite profuse. In the well-established cases it
is similar to the expectoration of pulmonary phthisis.
Treatment.—Arsenicum.-Mouth dry, red tongue, dry cough, scanty blood-
streaked sputa; edema, burning pain, flat bluish or red ulcers, separated laterally.
There is emaciation and marked weakness. The recent testimonials of old-school
authorities to the value of Arsenicum in wasting diseases is significant.
Belladonna is useful for the acute aggravations which occur.
Calcarea carb.-Marked scrofulous diathesis, gluey putrid sputa, perspira-
tion, affecting hands and feet.
Iodum.-Ulceration, tightness and constriction, soreness of larynx referred to
one spot, constant hemming, irritation, muco-purulent expectoration. It has a special
affinity for this disease, and may be found useful in all stages.
Kali bichrom.-Loose croupy cough; excoriating pain, great hoarseness,
yellow oval corroding ulceration; stringy expectoration with masses of tough muco-
purulent sputa. It controls the cough in cases where it is indicated, and exercises a
salutary effect upon the debilitated mucous membrane.
Merc. iod.-Increased secretion, especially in the morning; viscid saliva; hy-
VOL. I.-10
146
A SYSTEM OF MEDICINE.
pertrophic catarrh; parts swollen dark red. It controls the ulceration with abundant
secretion better than any remedy.
Nitric acid.-Great irritation; redness or anæmia; violent dry cough: spas-
modic, choking, and exhausting.
It will furnish, in some of the severe laryngeal coughs, brilliant results, relieving the
attacks promptly and for a considerable period.
Seleniate of soda.—I have confirmed Meyhoffer's statement of its value, par-
ticularly in those cases which are characterized by the expectoration of small lumps of
bloody mucus, and show a tendency to hoarseness The remedy is best suited to the
earlier stages of the disease.
Consult also Causticum, Drosera, Hepar sulph., Kali iod., and Sulphur.
Local Treatment.-Fowler's solution, fifteen drops to six ounces.
of water, a teaspoonful in an atomizing-cupful of water; inhale for
five minutes, three times a day. This is specially useful in ulcera-
tions. Under its use we see healthier granules spring up, and a more
rapid healing; if the case is not too far advanced, the ulcerations may
heal entirely. Glycerinated water, one part of glycerine to four parts
of water, with the tincture of iodine, two to five drops to an ounce, may
be used when the muco-purulent secretion is excessive. It not only
reduces the amount of secretion, but exercises a beneficial effect upon
the mucous membrane. Glycerine is exceedingly irritating to some.
throats; in such cases, its use is contra-indicated. Tannin, five grains.
to the ounce, also tends to diminish secretion. Carbolic acid, five to ten
grains to the ounce, may be used as an antiseptic. Argentum nitricum,
one to two grains to the ounce, as a stimulant. Mercurius cor., one grain,
first decimal trituration, to an ounce of water. In the treatment by local
applications, great care should be used that they are sufficiently mild.
No good can be accomplished by irritating the larynx; if it is left sore
and smarting for some hours after the use of a solution, injury is cer-
tainly done. The strength of the solution should be determined ac-
cording to the irritability of each larynx treated. It is preferable to
use the solutions with the atomizer than with a laryngeal brush, unless
the operator is exceedingly skillful, and can apply the brush carefully
only to the part which he desires to be touched. If the dysphagia is ex-
treme, morphia, four grains to an ounce of water, should be used to allay
the irritability. It may be applied with a brush to the posterior wall of
the pharynx, to the glosso-epiglottic folds, and the epiglottis. Freely
applied in this way, just before eating, it will afford the most marked
relief and enable the patient to take many a comfortable meal which
he would otherwise lose. It obviates the necessity in nearly every
case of the use of the œsophageal tube or of nutrient enemata.
Diagnosis. It is difficult at times to diagnose this disease from
syphilis if we are not sure of the history; but if the ulcerations have
an inflamed areola, are located in the pharynx and upper larynx, and
tend to heal under treatment, not specially painful and of a more
active grade, they are syphilitic. The swelling of the arytenoids, be-
fore mentioned, is diagnostic, as is also the anæmia. If the ulcera-
DISEASES OF THE RESPIRATORY ORGANS.
147
tions have a white base, and the mucous membrane surrounding them
is pale, that is, if there is not much inflammatory process, and the
ulceration exists in the lower portion of the larynx, at first, it is tu-
bercular. It may be mistaken for follicular laryngitis, but these
smaller ulcerations do not tend to separate, and there is more inflam-
mation about the mucous membrane when they exist.
SYPHILITIC LARYNGITIS.
Syphilis of the larynx will never be encountered after judicious
homoeopathic treatment. This disease naturally does not extend beyond
the tonsils and soft palate. If the larynx is involved, it is usually in
the upper part, namely, the epiglottis and the interarytenoid commis-
sure. The mucous membrane is congested, and ulcerations form
which are superficial in the second stage. In the tertiary, they are
deep, excoriating, with ragged edges and grayish base; they tend to
heal in one place, while spreading in another, as does syphilitic ulcer-
ation generally. They may destroy extensively the mucous and sub-
mucous tissue, perichondrium, and the cartilage. The epiglottis is
specially prone to be involved, and the destructive ulceration causes
extreme dysphagia. Condylomata may occur, although authorities.
vary as to their relative frequency. There are jagged or smooth, whit-
ish elevations, usually on the vocal cords, interarytenoid folds, or
where there is mechanical irritation in the larynx. Gummata afford
further evidence of tertiary syphilis; they are generally yellow pro-
jections, multiple, and followed by excessive ulceration.
Symptoms. They are such as are common to any form of ulcer-
ation; the pain is not marked, as it so often is in phthisis laryngis.
The offensive sputum is characteristic. Offensiveness seems to be the
brand of Cain set upon all syphilitic exudations. The voice is altered
and out of proportion to the lesion. Considerable contraction may
follow the healing of the ulceration.
Treatment.-Mercurius cor., 6th decimal trituration. This remedy promptly
effects the healing of secondary ulcers, especially when attended with considerable
secretion and an inflammatory areola about the ulcer, secretion of offensive sputa.
Kali iod.—Tertiary ulceration, particularly with tendency to rapid destruction of
tissue. Special symptoms are: a dry cough, with burning sensation in the larynx.
Nitric acid.-Great soreness, bleeding, and marked irritability. The remedies.
recommended in laryngeal phthisis may be consulted also.
Bichloride of mercury, 1 grain to 2 ounces of water, by inhalation, will be
found serviceable.
NEUROSES OF THE LARYNX.
These are, first, diseases of the motor system, and second, diseases
of the sensory system. The first division includes paralysis of the
muscles of the vocal cords and, second, spasms of the muscles of the
vocal cords.
148
A SYSTEM OF MEDICINE.
Paralysis may affect one of the vocal cords, causing what is termed
unilateral paralysis, or both may be affected, giving rise to bilateral
paralysis. The different forms result from implication of the various
muscles of the larynx.
UNILATERAL PARALYSIS OF THE ADDUCTOR OF ONE VOCAL CORD.
Definition. A condition in which one of the vocal cords not being
drawn to the median line, an attempted phonation produces partial
aphonia. Aphonia may also be induced by various inflammatory
affections, as we have already seen, and by mechanical impediments
to approximation of the vocal cords, namely, cicatrization or pressure
of tumors, indeed, there may be some change in the voice in nearly
all diseases of the larynx. Aphonia may result from certain forms of
cerebral disease, mild poisoning, etc., involving the spinal accessory
nerve and the recurrent laryngeal fibres.
Etiology. It may result from simple inflammation, but more
frequently from diphtheria than any other cause, though it may be
the result of poisoning by lead or arsenic. It also may be due to cere-
bral disease, when it is associated with paralysis of the same side of
the tongue or palate, or result from pressure on the pneumogastric or
the recurrent laryngeal nerves. It may be due to pressure on the re-
current laryngeal by tumors. The laryngoscope shows that one vocal
cord remains at the side of the larynx, and that the other is drawn to
the median line. The mucous membrane of the affected cord is gener-
ally hyperemic; there are no constitutional symptoms; aphonia is
present, and also dyspnoea. There is slight loss of voice, and some-
times complete aphonia. Coughing, laughing, singing, and sneezing
sounds are always altered in their character.
Pathology. There may be atrophy of the crico-arytenoideus later-
alis. Inflammatory exudations into the substance of the muscle may
induce this form of paralysis. In one case, that of a choir singer,
which followed a severe attack of laryngitis contracted in the winter, it
was several months before the partial aphonia, which was most mani-
fest in singing the lowest of a few notes, disappeared. No danger
attends the condition, the amount of dyspnoea as a rule being slight;
but when there are indications, such as paralysis of other organs, that
the disease results from cerebral lesion, the prognosis is very grave.
Treatment.-Nux vomica and Gelsemium are very useful in this
affection. The application of the laryngeal electrode of Mackenzie, by
means of which one pole can be passed into the larynx and the other
into the hyoid fossa, so that the current passes through the crico-ary-
tenoideus lateralis, is advised. The patient's general health should be
improved by the use of constitutional remedies.
DISEASES OF THE RESPIRATORY ORGANS.
149
BILATERAL PARALYSIS OF THE ADDUCTORS OF THE VOCAL CORDS.
This condition results in producing partial or complete loss of voice
from non-approximation of the vocal cords on attempted phonation;
there is dyspnoea which may be associated with paralysis of the pos
terior crico-arytenoid.
Etiology.-Hysteria furnishes the largest contingent of cases; the
condition results also from general debility. Cases of hyperæmia in-
duce this form of paralysis, which obtains long after the congestion
has subsided. Cases have been noted of intermittent aphonia said to
be due to malarial effects. Mackenzie reports having seen it induced
by cerebral lesions and from a tumor at the base of the brain. It may
also follow the excessive use of the voice by professional singers or elo-
cutionists.
Symptoms. This condition also is plainly manifest on laryngo-
scopic examination. Direct the patient to phonate "ah" or "e," and
it will be seen that the vocal cords do not move, or approach only
moderately; in all instances there is a marked space between them.
Since the vocal cords are fixed at the sides of the larynx, the condition
may be termed bilateral paralysis with lateral fixture. The voice is
partially aphonic; the cough is also without sound. In many cases
coughing and sneezing are attended with some sound, showing that
movements of a forcible character suffice to approximate the cords,
but in laughing, when, it is well known, the expirations are feebler,
there is no sound; the patient simply smiles. Generally the laryngeal
mucous membrane is somewhat anæmic.
Pathology. This disease is due to deficient nerve force in addi-
tion to the paralysis of the crico-arytenoidei lateralis; the arytenoides
postici may be involved.
Prognosis. It is generally favorable. In cases dependent upon
cerebral lesion it is necessarily very grave.
Treatment.-Belladonna, Nux vomica, Gelsemium, and Causticum
may be indicated. Faradization is recommended by Mackenzie; one
pole should be applied over the thyroid and cricoid externally, and the
other to the vocal cords. In this way Mackenzie has cured aphonia of
eight or nine years standing.
UNILATERAL PARALYSIS OF THE ABDUCTOR OF ONe Cord.
In this condition one vocal cord is not drawn aside, but remains
near the median line; upon inspiration, dyspnoea and stridulous
breathing result; there is only slight alteration of the voice.
Etiology.-Lesions which affect the pneumogastric or recurrent
nerves may induce this form of paralysis; exophthalmic goitre, from
pressure of the enlarged thyroid gland, also produces it. Enlarged
bronchial and cervical glands may induce it in children. Carcinoma
150
A SYSTEM OF MEDICINE.
of the oesophagus may also affect the recurrents. It is frequently
caused by central lesions of the nervous system. Inflammatory con-
ditions, giving rise to degeneration of the muscles, or to infiltration of
them, may likewise act as a cause; also aneurism of the arch of the
aorta and of the right carotid or of the carotids.
Symptoms. This condition is also plainly observed by laryngo-
scopic examination. When the patient attempts to inspire, the affected
vocal cord is not drawn to the side, as is normal, though its inner edge
does not remain exactly in the median line. The cords are often hy-
peræmic. The exact condition may be described as unilateral paraly-
sis with central fixture. Dyspnoea occurs on the slightest exertion, as
may be expected from the mechanical condition, but there is not as
much dyspnoea or stridulous breathing when one cord is affected as
when both are involved. There may be, owing to the marked influ-
ence upon respiration in this form of paralysis, signs of constitutional
disturbance, such as irritative fever.
Pathology.-Post-mortem examination shows that the muscle on
the affected side is wasted, while its fellow on the opposite side is
healthy and well nourished. In tumors, the affected laryngeal nerve.
has been found to be thoroughly incorporated with its mass, so that it
was impossible to trace its course.
Prognosis. The condition is exceedingly grave, as may be under-
stood from a consideration of its etiology, and an unfavorable opinion
should usually be given. There is some hope that relief may be ob-
tained through Faradism or Galvanism, either the electrodes of Macken-
zie or those of Ziemssen being employed. If symptoms of suffocation
are urgent, tracheotomy may be required. This condition may also be
favorably affected by Belladonna, Nux vomica, or Gelsemium.
BILATERAL PARALYSIS OF THE ABDUCTORS OF THE VOCAL CORDS.
In this condition both vocal cords remain fixed at the median line;
there is great dyspnoea and stridor on inspiration, attended with slight
aphonia.
Etiology. The causes of this condition correspond with those
which lead to paralysis of a single abductor; fortunately it is a very
rare affection, the conditions which give rise to it being likely to more
readily affect a single cord than both. It may result from a catarrhal
inflammation, giving rise to infiltration of the muscle, or from syphilis
inducing a degeneration of the muscular structure, or it may be the
result of hysteria.
Symptoms.-Laryngoscopic examination shows that the vocal
cords are not separated during inspiration. Bilateral paralysis with
central fixture is the real condition. There is a slight space between
the cords which is not generally changed except in forced expiration,
when there is complete approximation of the cords. The cords are
DISEASES OF THE RESPIRATORY ORGANS.
151
usually slightly hyperæmic; the voice is natural, or it may be harsh.
When the patient remains at rest, respiration is not seriously affected;
a slight effort, however, induces dyspnoea and stridulous breathing
with a croupy cough. Suffocative paroxysms occur, and in children
we have the symptoms of laryngismus stridulus. Constitutional symp-
toms appear, namely, febrile movement and wasting; in speaking, the
cords are not separated except to the measurement of one or two
lines, and the lips of the glottis are drawn downward below their
natural plane.
Pathology. The condition is due to loss of power of the aryte-
noidei postici, and primarily results from deficient nerve force in the
pneumogastric and recurrent laryngeal. The muscles are found atro-
phied after death, and there exists generally atrophy of the nerve
structure.
Diagnosis.-Laryngoscopic examination enables us to diagnosti-
cate the condition with certainty. The approximation of the cords
during inspiration, with a narrow chink only one or two lines in width,
is manifest, and their forcible opening upwards during expiration is
also significant. The continued inspiratory stridor also renders the
diagnosis easy.
Prognosis. This is grave, not only from the danger of suffocative
paroxysms, but from the fact that it results from serious lesions in
other parts.
In children or in adults, when inflammatory action
supervenes, the danger from cedema glottidis becomes very great.
Treatment.—In cases resulting from hysteria, Ignatia may be of
benefit; if we have a sodden condition of the muscles from catarrhal
inflammation, Arsenicum and Nux are to be considered. If it results
from syphilis, Mercurius sol. or the Iodide of potassium may be useful.
Electricity, as before directed in other paralytic conditions, may be
employed, but it is not generally effective. Tracheotomy must be re-
sorted to if the suffocation becomes extreme.
PARALYSIS OF THE THYRO-ARYTENOID MUSCLES.
This lesion is either unilateral or bilateral, and is not uncommon,
being found associated with paralysis of the crico-thyroid muscles and
of the abductors of the cords.
Etiology. It may occur from violent exercise of the voice, par-
ticularly when there is inflammation of the larynx, or when the voice.
is changing.
Symptoms. We have a coarse voice, its pitch is high, and there
are pain and fatigue on talking. When it occurs with paralysis of the
muscles above mentioned, partial or complete aphonia may obtain, or
the voice be feeble. On laryngoscopic inspection the vocal cords are
separated on phonation throughout their whole extent; in unilateral
paralysis there is, of course, less gaping.
152
A SYSTEM OF MEDICINE.
Treatment.-Nux vomica and Gelsemium act well in this condi-
tion. The Del Sartian or some other good method of exercising the
voice should be employed; the use of the Faradic current has been
followed by good results.
LARYNGISMUS STRIDULUS.
The most interesting of all the neuroses of the larynx is what is
termed laryngismus stridulus, which is a spasm of the vocal cords, con-
sisting of a sudden, temporary, and partial or complete closure of the
glottis, with dyspnoea, stridulous breathing, and cessation of respira-
tory movements.
Synonyms. Spasm of glottis, Millar's asthma, Asthma thymi-
cum, False croup, Child-crowing; Laryngite striduleuse; Kehlkopf
Krampf.
Etiology. The same uncertainty still exists concerning this part
of the subject that has always attended it. Once it was regarded as
exclusively of cerebral origin. Many cases are now known to arise
from reflex irritation, and a strumous diathesis is undoubtedly a pre-
disposing cause. Slight exciting causes in cases ripe for the disease
suffice to induce an outbreak. The irritation of teething, indigestible
food or parasites in the bowels do not sensibly affect healthy children,
while a current of cool air over the surface will induce a laryngeal
spasm in a proper subject. A rachitic state of the cranial bones has
been noted in those who are subject to this affection. It may be cen-
tral, that is, there may be hyperæmia or a serous exudation near the
origin of the pneumogastric nerve. Disease of the cervical portion
of the spinal cord is regarded by Marshall Hall as occasioning it.
Hydrocephalus, in some cases, and mental emotions, terror, anger, etc.,
have induced a spasm.
Symptoms.-The attacks are minor or major. The child may be
slightly peevish for two or three days previous to the attack; in minor
cases it wakens suddenly with dyspnoea, and there is a crowing in-
spiration, similar to croup. These recur on succeeding nights or at
other times. Under the influence of treatment, or because the child
is especially vigorous, they may cease and there be no further trouble.
If, however, the child is delicate or of markedly strumous diathesis,
the lighter attacks increase in severity, or from the first the paroxysm
may be violent. In the major cases, dyspnoea suddenly becomes very
urgent, the inspiration is prolonged and has the characteristic long-
drawn whoop, the eyeballs roll, the veins of the neck are turgid; carpo-
pedal spasms occur; sometimes there is simply the flexing of the
thumb; again, both hands and feet may be drawn. Rarely a general
There is com-
convulsion occurs. All sound of the voice may cease.
plete closure of the glottis, and respiration is temporarily suspended ;
the bluish countenance gives way to pallor and then to lividity; for
a few seconds the child is apparently dead, then, under the action of
DISEASES OF THE RESPIRATORY ORGANS.
153
stimulants, it respires a few times, to resume again the stridulous breath-
ing; there is now no spasm present. The child is weak and debili-
tated, but soon breathes as before. Several hours or days may elapse
between the spasms, but they are prone to return. In case remedies
do not control them, death may occur in one of the most severe attacks.
There is no febrile movement.
The Diagnosis is easy. It only resembles croup, which has marked
inflammatory action, and has not the entire absence of symptoms
between the paroxysms.
The Prognosis is grave in cases dependent upon central origin;
when due to reflex irritation it is much more favorable. The danger
will, however, depend largely upon the child's dyscrasia; if it is
markedly scrofulous, the case may be regarded as serious from the
start. From my own experience I am not inclined to take so gloomy
a view as some of laryngismus stridulus, though I confess to noting.
even the lighter symptoms with a considerable degree of anxiety.
Thus far, in an experience of twenty years, I have only had one case
die, and that was during a severe spasm which occurred in my absence.
I had warned the attendants carefully how to proceed, as I had before
done with success, but they failed to relieve the spasm.
Treatment. The first object is to relieve the spasm of the glottis,
which is done as follows: Quickly strip the child and place it in a
hot bath, being careful that the water is not too hot; then pour cold
water upon the head and chest. This simple expedient, promptly
carried out, has never failed in my hands to bring a child at once out
of a spasm. The inhalation of chloroform, so useful in many forms
of spasm, may be of advantage, but its action is not generally prompt
enough. If there is no relief to the apnoea, and the child is sinking
fast, tracheotomy must be performed. In reflex cases, if the child is
teething, the gums should be promptly lanced; if the stomach is
loaded with indigestible food, an emetic should be administered; if
there is preputial disease, a surgical operation should be performed at
once. The spasms having been relieved, it is then of paramount im-
portance for us to prevent their recurrence, which may be effected
with remedies.
Gelsemium is of great value. It approaches more nearly to a specific than
any remedy we have. I rarely find it necessary to use any other. Four cases lately
treated have confirmed my idea of its efficacy. I have used it in all forms of the
disease. Its special indication is said to be a long inspiration with a short, sudden,
violent expiration.
Sambucus.-In cases when the patient awakes with a sudden attack, attended
with marked dyspnea, which usually occurs from midnight until morning. Alterna-
tion of perspiration and dry heat. Inspiration more labored than expiration, and
cough not frequent.
Chlorine.—In cases when the expiration is greatly impeded. Excitable chil-
dren. The child is cyanotic and partially unconscious.
Consult also Aconite, Arsenicum, Belladonna, Iodine, Moschus,
Ignatia, Cuprum, Nux vomica, Lachesis.
154
A SYSTEM OF MEDICINE.
Varieties.—There is occasionally a serious form of spasm of the
glottis attacking adults. The affection is of a hysterical nature.
DISEASES OF THE SENSORY SYSTEM OF THE LARYNX.
These are hyperæsthesia and anæsthesia.
Hyperæsthesia.-This is an affection very rarely met with. It
manifests itself in an increased sensibility of the larynx, which is not.
dependent upon any inflammatory disease or organic change in its
tissues. It occurs either as an intermittent disease or without period-
icity. It manifests itself by a disposition to violent spasmodic cough.
It is unattended with febrile movement or with any indications that
it has resulted from exposure to cold. These attacks are not like
those which occur in laryngismus stridulus, being merely violent
paroxysms with the usual laryngeal characteristics.
I was called in consultation to see such a case more than six years
since. The parents feared that the child was going into consumption,
so constant and violent was the cough. There was no evidence, how-
ever, of its being of other than neurotic origin, and it yielded after a
time to remedies based upon this theory.
Some cases are characterized by severe neuralgic pain, referable to
the larynx. There is extreme sensitiveness to pressure, and an ex-
aggerated sense of constriction; a feeling of a feather in the parts, or
of some other foreign body, burning or scraping; in fine, merely an ex-
aggeration of the sensations which are common to laryngeal affections.
Consult Aconite, Cuprum, Opium, Belladonna, Gelsemium, Lachesis,
Ignatia. Locally: Inhalations of hot steam and a solution of mor-
phia, four grains to the ounce, may be of service.
Anæsthesia occurs very rarely as a distinct disease. If the pneu-
mogastric nerves or their laryngeal branches are diseased at their
origin, or anywhere in their trunks, we may have a diminished sensi-
bility of the larynx. If the nerve supply has been entirely cut off,
either from pressure of a tumor or from destructive diseases, the sensi-
bility may be entirely destroyed.
Romberg noticed that in cholera there is impaired sensibility of
the larynx, and Mackenzie (Reynolds, vol. ii., p. 36) states that some
morbid phenomena of a functional character, such as a vocalist's in-
ability to produce certain notes which previously could be easily
formed, are probably, in some cases where the larynx appears healthy,
due to impaired muscular sensibility.
Treatment.—If the nerve supply has been cut off, it is, of course,
impossible to right this affection. If it be due to debility resulting
from cholera or from any severe acute disease, such as typhoid fever,
the building up of the general health will be likely to restore the func-
tional power of the larynx. As internal remedies, Gelsemium, Nux,
DISEASES OF THE RESPIRATORY ORGANS.
155
and Arsenicum will be likely to furnish relief, but the main reliance
must be placed upon increasing the tone of the general system.
TUMORS OF THE LARYNX.
Definition. These are new growths, either simple or malignant,
existing as distinct tumors which project from the mucous membrane
of the larynx. They are neoplasms, with a well-marked lining of
demarcation from the subjacent tissues.
Synonyms. (Latin) Polypus laryngis; (French) Polypes du lar-
ynx; (German) Kehlkopfpolypen, Neubildungen im Kehlkopfe; (Eng-
lish) Polypus of the larynx, warts, neoplasms, excrescences and can-
cerous growths.
Etiology. While benign growths of the larynx have as their
immediate exciting cause a local hyperæmia, resulting from chronic
inflammation of low degree but persistent, we are of the view that
there is a predisposition to their development which must be consid-
ered as resulting from another condition. While such eminent au-
thorities as Mackenzie believe that neither syphilis nor phthisis predis-
poses, the opinion of other authorities differs.
Mackenzie states neither syphilis nor phthisis, nor any constitutional
condition, appears to favor the growth of these morbid inflammations;
indeed, both these diatheses appear to exercise an influence decidedly
antagonistic to the development of new formations.
Solis Cohen mentions 66 cases of morbid growths, of which 31 oc-
curred without apparent constitutional disturbance, 22 were associated
with phthisis, and 8 with syphilis. The cases which have come under
my own observation in the Central Homœopathic Dispensary have
originated either from a phthisical or syphilitic basis. The persistent
hyperemia which results from syphilitic congestion would certainly
favor the proliferation of connective tissue which lies at the foundation
of these growths. The same natural formation of a soil favorable to
neoplasms exists in phthisis. Dr. Mackenzie admits that laryngeal
growths may occur in syphilitic persons as they do in health, but that
syphilis does not appear to be a factor in their production. It is ap-
parently true that tumors of the larynx occur less frequently in the
special practice of homeopathists who treat the throat, which would
argue that they are less common where milder applications are made
to the larynx. The irritation induced by severe local treatment may,
in my judgment, result at times in the development of these neo-
plasms. We cannot always ascertain the origin of these growths.
When the predisposition exists, undoubtedly a local catarrh acts as an
immediate exciting cause. They occur at all ages, being either con-
genital or found in those of eighty years, or more, most frequently in
the male; from twenty to forty-five is the age at which they are most
156
A SYSTEM OF MEDICINE.
common. Carcinomatous growths of the larynx result from peculiar
states of the tissue which at present are not fully understood.
Symptoms. Many of the symptoms which belong to tumors of
the larynx are similar to those of chronic laryngitis, so it is not always
easy from the subjective symptoms to be certain of the existence of a
tumor; but there is, as Cohen says, a characteristic dull timbre to the
intonation which is suggestive of mechanical obstruction, and differ-
entiates it at once from the hoarseness and dysphonia of other cases.
There is a sensation as of a foreign body in the larynx, which some.
patients observe; but with others there is no feeling of fulness or
oppression in the parts. Most cases are not characterized by any pain.
In some instances the presence of a tumor is not suspected at all from
any subjective symptoms. A cough may occur, though it is not com-
mon, except in cases where the tumor is near the glottis, or when it is
vascular and excites cough from hæmorrhage. In large tumors the
cough resembles croup. We may have a dry, hacking cough, or moist,
and attended with expectoration of considerable mucus, with the voice
often changed, since tumors of the larynx most frequently originate
from the vocal cords; growths which do not interfere with their vibra-
tion do not affect the voice. When they are situated between or
underneath the cords, even though they are of small size, marked
hoarseness results; if the growths do not project within the chink of
the glottis, or impede vibration by pressure, there is no serious inter-
ference with the voice. The alteration of the voice is sometimes in-
termittent, occurring only when the phonation of the cord is tem-
porarily interfered with. Complete aphonia is rare, and only occurs
when a large growth fills up the rima glottidis. Dysphagia is common
only in those cases in which the growth is large, and particularly affects
the parts concerned in deglutition, or extends towards the oesophagus.
Dyspnoea is present if the tumor is sufficiently large to materially in-
terfere with the rima glottidis, or if its pressure impairs the action of
the laryngeal muscle. Stridulous breathing exists in such cases. The
expectoration is usually increased, and sometimes, in cases of morbid
growths, particles of the tumor may be found in the expectoration.
The dyspnoea will vary from slight impairment of breathing to threat-
ened asphyxia.
Physical Signs.-On inspection, the external configuration of the
larynx is found to be changed. If the tumor is large, there is a marked
bulging of the external parts.
Laryngoscopic Appearances.-We have no difficulty in dis-
tinguishing by laryngoscopy the presence of a tumor, as well as the
variety to which it belongs. The most common forms are termed
papilloma. They are usually whitish in color, sometimes pink or deep-
red. They vary in size from a grain of mustard to a grape; usually
they are about the size of a split pea. Their development is most fre-
DISEASES OF THE RESPIRATORY ORGANS.
157
quently from the vocal cords, and they are generally mammillated, lob-
ulated, or like a cauliflower excrescence, and are sessile and multiple.
Fibromata are generally larger, and occur less frequently. Their size
is from that of a split-pea to a grape; about half the cases spring from
the vocal cords; they are single and pedunculated.
Fibro-cellular tumors are more rare, and, according to Mackenzie,
represent only about 5 per cent. of the laryngeal growths. They are
sometimes of the size of a grape, but usually smaller; they are always
pedunculated, and of a pale pinkish color.
Cystic tumors exist as round, egg-like projections of a white or red-
dish color, and with an area of congested mucous membrane around
them. Their development is from the laryngeal surface of the epi-
glottis, or from the ventricles; they are filled with sebaceous matter.
Myxomata, carcinomata, adenomata, lipomata and angiomata are
all exceedingly rare.
Carcinomatous growths are very irregular in form, and marked by
the tendency to destructive ulceration or to thickening of the tissues.
The most frequent sites from which carcinoma develops are the epi-
glottis and ventricular bands. According to the extent of the growth,
there may be displacement of parts. The epiglottis may be pushed
to one side, and the laryngeal folds may be swollen to such an extent
as to obstruct the view of all the parts below.
Course and Termination.-The benign tumors are of slow de-
velopment, and may not change their size, sometimes, for years. Un-
doubtedly, cases exist which afford so little trouble to the patients
that their presence is never known; when, however, their condition
becomes specially inflammatory, they are a source of great irritation,
and tend to produce suffocation.
Epithelial cancer may exist without much pain, but usually deglu-
tition is exceedingly painful and difficult; it is attended with expec-
toration and some dyspnoea.
Encephaloid cancer progresses rapidly, and the constitutional symp-
toms are grave. The difficulty of deglutition produces waste and pros-
tration, and the tendency is eventually toward suffocation.
Pathology. It is impossible to understand the tissue condition
which gives rise to one form of morbid growth rather than another.
In a general way we are able to assume that they are the result of some
perversion of the nutritive process. Their basis is a local hyperæmia,
but in view of the many cases which we have, in which local hyperæ-
mia, even very persistent, does not result in the formation of any neo-
plasm, we are led at once to the belief that there is a special tissue-
dyscrasia which influences their early formation and growth. In the
order of frequency the growths are papillomata, fibromata, fibro-cellu-
lar tumors, cystic tumors, carcinomata, and lipomata. Three-fourths
of all the laryngeal growths of a benign nature are papillomata.
158
A SYSTEM OF MEDICINE.
Paget, describing these neoplasms, says: "In their general form and
arrangement they have many points of resemblance, but on an en-
larged scale, to the papilla which, in various localities, constitute nat-
ural projections from free surfaces, more especially from the skin and
mucous membrane. Their substance is formed of connective tissue,
which is continuous with that which normally exists in the part, whilst
the free surface is covered by the epithelium which may vary in thick-
ness and its number of layers, according to the seat of the tumor. Blood-
vessels and even nerves enter into the interior of the papillæ." From
this description we are led to the belief that they are actual enlarge-
ments of the papillæ rather than conditions resulting from some per-
version of the nutrition of these parts as they normally exist.
Cohen relates" in addition to these tumors, a curious form of morbid
growth, consisting of bands of membrane stretching from one vocal
cord to another." Microscopic examination of papillomata demon-
strates that they consist of more or less perfect connective tissue clothed
with layers of epithelium. Hydatids, cartilaginous tumors, and erec-
tile growths are seen occasionally.
Diagnosis. This is readily made by means of laryngoscopic ex-
amination. We generally distinguish the benign tumors from the
fact that they are much more markedly defined, and rarely are found
ulcerated, while the malignant growths are irregular, and attended.
with great thickening of tissue and, often, ulceration.
Syphilitic condylomata are irregular white elevations situated on
the congested mucous membrane, and are not very marked as tumors.
The history of the case, as well as the ease with which they disappear
under anti-syphilitic treatment, aids in diagnosis.
Laryngeal phthisis is usually diagnosticated from the co-existence
of pulmonic lesion, and from a peculiar pallor and disposition to
oedema. Abrasion of the ventricle is sometimes seen, but it occurs so
rarely that there is little likelihood of an error of diagnosis in this
regard. Ulceration of the larynx sometimes presents fungus-growths,
but they have not the definite appearance of tumors.
Prognosis. This depends entirely upon the form of tumor. The
benign tumors are susceptible of removal, but carcinoma of either form
always proves fatal.
Treatment. Some of these tumors, particularly the papillomata,
undoubtedly will disappear under the use of internal remedies. They
should be faithfully tried when the case is not urgent. Calcarea carb.,
Teucrium, Graphites may be employed against papillomata; Conium
and Silicea against fibromata; Acetic acid for fibro-cellular, Apis and
Arsenicum for cystic tumors; Arsenicum, Acetic acid, Aurum, Car-
bolic acid, Conium, Hydrastis, Lachesis, Kali hyd., Phos., Zincum
against carcinoma.
The removal of the neoplasms is possible when the physician is an
DISEASES OF THE RESPIRATORY ORGANS.
159
expert in the use of the various instruments which have been devised
by Mackenzie, Storck, Ziemssen, and others.
The treatment of these growths is especially difficult to one at all
accustomed to the use of the laryngoscope and the introduction of in-
struments within the larynx. The majority of cases are undoubtedly
removed, but their destruction is the result of crushing, which pro-
duces an atrophy of the growth. It is best to accomplish their
removal with the tube-forceps or the écraseur. They may also be
snipped off with the laryngeal scissors.
The galvano-cautery is not to be recommended, since it is apt to in-
duce very severe pain and subsequent inflammation. The same can
be said of caustic solutions which may, at the time of their use, induce
a spasm of the larynx, with a possible fatal termination. In the case
of very large growths, resort must be had to tracheotomy. No effort
should be made to remove cancerous growths. The pain may be re-
lieved by the internal administration of Arsenicum, Lachesis, or Co-
nium, and by the inhalation of hot steam to which morphia has been
added in sufficient amount to produce relief. It will be found that
relief may be given for a long period of time by commencing the use
of the anodyne in very light doses, increasing the amount very slightly
as the absolute need of the patient requires.
CROUP.
Definition.-Croup is an inflammation of the larynx, at times ex-
tending to the trachea and bronchi, attended with an exudation on
the mucous membrane, and inducing hoarseness, dyspnoea, a sharp
ringing cough, and spasm of the glottis.
Synonyms.-Cynanche laryngis, Laryngo-tracheitis, Cynanche
trachealis, Angina membranacia, Pseudo-membranous laryngitis, Suf-
focatis-stridula; Laryngite striduleuse.
True croup is not infantile laryngitis nor diphtheritic laryngitis ;
there is a distinct and separate affection in which, combined with the
symptoms of laryngeal inflammation, there is an exudation which
tends, primarily, to invade the larynx. The obscurity in which this
subject has been involved, undoubtedly has arisen from the fact that
the main sources of error have been in confounding the severe grades
of infantile laryngitis without exudation and some cases of diphther-
itic laryngitis. We shall see that a distinction can be established
which places croup nosologically as an independent disease.
History. There is so much confusion on this subject that it is not
necessary to follow the history of croup closely. Home remarks that
probably it has existed more or less in all ages, following some pre-
disposing cause which must have been operative even as now. It has
been confounded with pseudo-laryngitis, pertussis, capillary bronchi-
tis, laryngismus stridulus, and diphtheria. Baillou first noticed croup
160
A SYSTEM OF MEDICINE.
in an epidemic of whooping-cough in Paris in 1576. In England, Dr.
P. Blair, in 1713, gave the distinctive points between it and whooping-
cough, and first used the word croup, which signifies strangulation.
F. Home, in 1765, established our knowledge of it as an acute inflam-
mation of the larynx and trachea. The distinction was followed with
varying accuracy by succeeding writers. Of late years, the most in-
teresting question has been the identity or non-identity of croup and
diphtheria, which has been discussed with great ability in America,
France, Germany, and England by eminent men. The question is
yet manifestly unsettled. The lines of demarcation, however, seem to
us very strong. Diphtheritic laryngitis is not croup, as we describe it
here. It is a distinct and different form of disease. In the tables of
differential diagnosis given by Leischmann, Cohen, and others, differ-
ences are given which, though they may blend at times, are yet, to
our mind, discriminative. The discussion on this subject is only
another illustration of the futility of attempting to settle on a definite
name for a train of symptoms. A perfect nosology will never exist
until each separate case in each separate individual has a name.
Hahnemann hit the nail squarely when he coined the phrase, “The
totality of the symptoms constitutes the disease." The most sug-
gestive points of distinction between the two diseases are as follows:
CROUP.
Asthenic and local inflammation.
Not contagious.
Larynx is attacked first.
No paralysis.
Sporadic usually.
Rarely attacks adults.
Always has exudation.
Fatal by stenosis.
Not inoculable.
DIPHTHERIA.
General and asthenic inflammation.
Contagious.
Fances and nares first invaded.
Paralysis often follows.
Usually endemic or epidemic.
Frequently attacks adults.
May be without exudation.
Death without impediment to respiration.
Inoculable.
We do not believe it right to establish a difference between two dis-
eases merely from the fact that in one the exudation takes place upon
the free surface of the mucous membrane, and in the other within the
tissue, but we do maintain, from the weight of evidence in the case,
from the combination of all the clinical and anatomical facts, that it is
possible to establish an absolute dissimilarity as between croup and
diphtheria. If we accept the views of some standard authorities on these
points, we see no reason why true croup should be in any way described
separately from diphtheritic laryngitis, since it is regarded merely
as a variety of this latter affection, which may occur in different forms.
The most convincing clinical distinctions lie in the fact that true
croup, or membranous croup, begins with decided laryngeal symp-
toms, and that its exudation takes by preference the larynx. It is true,
we may, at times, have an exudation extending into the pharynx, in-
DISEASES OF THE RESPIRATORY ORGANS.
161
volving its posterior wall, the soft palate and uvula, but its tendency
is to the formation of the exudate in the larynx mainly. The exact
opposite always occurs in diphtheria; at least, if there are exceptions
to this rule, they are exceedingly rare. The exudate forms first on the
pharynx, and it is generally many days, or a number of days, before
the exudation involves the larynx. Diphtheritic laryngitis, therefore,
is a secondary affection, while true croup is a primary one.
The secondary or symptomatic croup, which is described as follow-
ing pyæmia, notably the exanthems, measles and scarlatina, and also
that accompanying epidemic diphtheria, is undoubtedly diphtheritic
in its character.
Etiology. Croup is a disease of childhood, occurring most fre-
quently from the first to the tenth year, very rarely after that. It is
not as common in the first year as in the second and third. Its great-
est mortality is in the second year. Boys are attacked more often than
girls, and suffer a greater fatality. Ruehle gives the proportion of
boys to girls attacked as 3 to 2.
Climate has a great influence in its production. A cold northeast
wind has a special quality. which induces attacks of croup. A child
may be exposed to a considerable degree of cold in our country with-
out laryngeal inflammation, but the croupy sound appears after trivial
exposure to an east wind. There is, undoubtedly, some peculiar char-
acteristic which is possessed by a north or northeast wind, which di-
rectly influences an attack of croup; it is not the temperature, for
after exposure to a west or southwest wind, with a far greater degree of
cold, there is much less liability to attacks of croup.
Season has also its effect. The larger number of fatal cases occur
in winter and spring. Summer and autumn usually have the least
fatality. The character of the season has, however, great influence.
A cold spell, with prevalence of damp winds, will result in the pro-
duction of many cases, and in an increase in fatality.
Out of 467 epidemics of croup, collected by A. Hirsch, 159 belonged
to winter (December, 56; January, 48; February, 33); 130 to spring
(March, 51; April, 42; May, 37), 72 to summer (June, 21; July, 24;
August, 38); and 106 to autumn (September, 22; October, 41; Novem-
ber, 42).
—
Predisposing Causes. First, Heredity. The children of
phthisical, carcinomatous, or insane parents are particularly liable; the
inexorable diathesis renders the offspring of these much more disposed
to such attacks. Hereditary croup has always a taint behind it. A
fine complexion and a florid face, though fair to look upon, are the
heritage often of these children, and the sensitive skin renders them
more susceptible to cold. It is difficult to understand why such an
author as Steiner should assert that there is no evidence that scrofu-
losis specially predisposes to croup. He, however, admits that there
VOL. I.-11
162
A SYSTEM OF MEDICINE.
is a certain hereditary and family disposition to croupous inflamma-
tion in general, and to laryngeal croup in particular, but he does not
believe that this hereditary predisposition is especially noticeable in
children whose parents have been subject to tonsillar enlargement, or
that it originates in scrofulosis.
The disease does not tend to recur. Steiner states that in an experi-
ence of more than 100,000 cases of the disease among children, he has
never yet met with a single instance of true croup occurring twice. It
is found that in the instances which have been recorded of attacks of
croup occurring a number of times, the affection has been mistaken.
for false croup.
Food has no influence other than that good nourishment tends to
ward off any form of disease. Ill health, from any cause, makes chil-
dren more liable to croup.
The exciting cause is always some exposure to cold and dampness.
It is found that dampness directly influences the prevalence of croup.
The draining of marshes has been followed by a diminution in the
prevalence of croup, as is shown by Crawford's observation (Ziemssen,
vol. iv., p. 237). Cold, dry winds do not so frequently influence the
attacks.
Symptoms. The child is usually attacked towards night; there
is, early, slight fever, with or without coldness, increasing often rap-
idly; hoarseness is generally present, but may be of moderate degree.
The cough has its peculiar characteristic form, though it may occur
infrequently for a day or two. The first night the child usually sleeps
well, awakening only once or twice; the second night the febrile
movement is rather increased, and the peculiar hoarse, ringing sound ·
of the cough more pronounced. There is no coryza; indeed, the se-
cretions seem checked. The urine is particularly prone to be dimin-
ished. The pharynx will be found hyperamic; sometimes the red-
ness is slight, and sometimes quite intense; there is also enlargement
of the tonsils. These are the phenomena of the first stage.
Between 9 and 12 o'clock, usually, on the second or third night, the
child wakens with decided dyspnoea; it starts in a fright, the eyes
stare, terror is depicted on its face; the inspiration is wheezing, pro-
longed, and stridulous, especially after the cough. The expiration is
prolonged; the face is red, then purple; the child clutches at its throat
and extends its arms. Every effort at coughing produces a harsh,
ringing, and barking sound; eventually, there may be little or no
sound when the child coughs. The dyspnoea, which is always present,
is due to a veritable spasm of the glottis. The irritation may extend
to the terminal nerve filaments of the bronchioles, and add very much
to the apnoea. The attacks of dyspnoea may last a few moments or,
exceptionally, an hour, or more, but they tend to recur. There is rarely
enough exudation to produce complete stenosis. When the dyspnoea
DISEASES OF THE RESPIRATORY ORGANS.
163
is great we have inspiratory retraction. During inspiration the chest
expands without sufficient air entering, a partial vacuum is formed,
and the epigastrium sinks. The respiratory movements are also de-
ficient in power. These are the symptoms of the second stage.
At times, during the progress of the dyspnoea, we have what are
termed the suffocative attacks. The child is intensely restless, calls
out to be walked, and, after having been walked awhile, begs to be
placed back in bed, then rises to insist again upon movement; if in
bed, kicks off the bed-clothing; the face shows the greatest anxiety;
the veins are swollen and the eyes protrude, and there are, in fine,
marked indications of impending suffocation. After these attacks we
have the third or last stage, that of asphyxia.
In addition to the dyspnoea, we have carbonic-acid poisoning. In-
stead of the flushed face, the skin grows pale and of a shining hue;
instead of an agitated look, the expression becomes indifferent and
dull, the eyes droop, and there are all the indications of languor and
depression. Cyanosis obtains to a considerable degree in all portions
of the mucous membrane which are visible. The respiratory move-
ments are more quiet and superficial, and we lose the pronounced.
stridor. At times, there are violent efforts made for breath, but the
patient soon sinks again into a comatose condition. At this time
there is a very rapid, feeble, and intermittent pulse. The extremities
are cold, there is loss of sensibility in the skin, the perspiration is cold.
and clammy; there is partial unconsciousness and, sometimes, slight
convulsive movements, and the fatal result occurs, if it takes place at
this time, from exhaustion. Sometimes it is not possible to establish
any line of demarcation between the different stages. In what is
termed the fulminant form, the child wakens suddenly on the first.
night with all the symptoms of intense dyspnoea, such as we have in
an ordinary case of false croup, but, from this time on, the symptoms
rapidly increase in severity, suffocative attacks soon appear, and the
stage of asphyxia follows closely.
Special Symptoms.-Breathing.-The peculiar breathing of
croup, which gives it its distinctive character, and which has the sound
which is most dreaded by the parents and physician, is due to the
fact that, notwithstanding the labored breathing, only a small quantity
of air is able to pass through the narrow glottis. There is prolonged
inspiration, and a wheezing, whistling, snoring sound, sometimes heard
for a long distance. It has a sibilant, tubular, metallic quality, and
its pitch is high. In one case which was under my charge, it was
scarcely possible to find any part of the house so distant that the dis-
tressing sound could not be heard. The expiration is marked, and
accompanied by the rattling of mucus, and is distinguished from the
sharper and sawing nature of the inspiratory sound by its low tone
and snoring quality. The breathing usually continues to manifest
164
A SYSTEM OF MEDICINE.
these characteristics from the time the second stage is reached until the
end, or until there has been relief to the dyspnoea.
The respiratory sounds are also distinctive; they are notably de-
ficient, but if, during the prevalence of dyspnoea, they become increased
in frequency, they are not effective. The supra-clavicular spaces are de-
pressed during inspiration; the intercostal spaces do not bulge, nor do
the chest-walls expand to the normal extent. The inspiratory retrac-
tion, which has been before noticed, is significant of marked dyspnoea.
The febrile movement is not marked after the first or second day. The
temperature may rise as high as 102° or 103°, but ordinarily it will be
found to be about 100,° and on the third or, at least, the fifth day, it
will subside. In those cases where it is found up to 104° or 105°, we
shall find that extensive bronchitis or pneumonia exists. The pulse,
early, is full, hard, and from 120 to 130. In the second stage it con-
tinues at about this rate, except that during the suffocative spells it may
rise 20 or 30 beats; in the last stage it becomes very rapid, 160, or even
180, small, compressible, and intermittent. A persistent high tempera-
ture is significant either of diphtheria or catarrhal laryngitis.
The dyspnoea is one of the evidences of the disease. It is the re-
sult of laryngeal stenosis, and marks the advance of the second stage.
The respirations rise from 28 to 32 per minute, sometimes more; all the
accessory muscles are brought into play. The child throws the head
upward with each respiration, somewhat after the manner of the asth-
matic. His whole efforts are bent upon expanding the chest. The
inspirations grow more labored as the laryngeal contraction increases;
the mouth is opened widely. The alæ nasi now contract, and again
are widely open; the larynx is depressed after each inspiration, and
the cartilages of the lower ribs are drawn inwards.
Different opinions have been expressed as to the cause of this dysp-
noa. Niemeyer has advanced the view that it is dependent mainly
upon paralysis of the laryngeal muscles. He regards this paralysis as
the result of the infiltration of the mucous and sub-mucous tissues
which exerts pressure upon the muscles and renders them sodden and
powerless. An important clinical fact is brought out by this considera-
tion, for in paralysis of the laryngeal muscles inspiration is affected,
being rendered prolonged and stridulous while the expiration is easy;
difficulty in both inspiration and expiration indicates that there is an
exudation, or a contraction of the glottis from oedema.
I once had an opportunity to make a post-mortem examination in
the case of a child that had died from a severe attack of false croup,
which, throughout its history of eleven days, simulated constantly the
symptoms of membranous croup, with the exception that there was
at no time evidence of exudation. We had, however, every other
symptom characteristic of membranous croup. The child died during
one of the suffocative attacks. There was no evidence of any membrane
1
DISEASES OF THE RESPIRATORY ORGANS.
165
in the larynx, nor was there any evidence of the severe dyspnoea to
which the child had been subjected; there was a slight trace of œdema
glottidis, but entirely insufficient to account for the dyspnoea and pro-
longed stridor. The parts were not hyperæmic, though, of course,
this is explained by the well-known fact that the laryngeal mucous
membrane is rich in elastic fibres, and we often find it free from hyper-
æmia after death, when previous laryngoscopic examination had shown
an intense degree of congestion. This case of stridor and dyspnoea,
which was worse upon inspiration, was undoubtedly due to inflamma-
tory extension so far affecting the muscles as to interfere with their
proper action. There was no evidence that the difficulty was in any
way due to central nervous lesion.
Rudnicky* claims that the dyspnoea of croup is due to lack of co-
ordination of the respiratory movement from nervous irritation. He
insists that there is a special disturbance of the nerves, and that it may
be outside the larynx. He refers to the fact that the branches of the
superior laryngeal and recurrent nerves have many ganglionic cells,
which are provided before their separation into muscular subdivisions.
They are true ganglia, from which distinct bands of nerve fibres may
extend to the muscular layers of the larynx. Rudnicky contends that
Niemeyer's theory is not correct, as was evidenced from laryngoscopic
examinations which he made, demonstrating that the vocal cords
move as usual during the existence of croup, thus showing there could
be no paralysis. Ziemssen (vol. iv., p. 242) regards the dyspnoea of
croup as the combined result of several causes, acting together or in
succession, the most common of which is, undoubtedly, a mechanical
one, namely, the swollen, relaxed, and intensely-congested state of the
mucous membrane of the larynx on the one hand, and the false mem-
brane and muco-purulent secretion on the other. He says that every
one who has had frequent opportunities for observation after death of
the anatomical changes in the larynx of children, and who considers.
how little is needed to block up the glottis in such patients, must be
justified in inferring the intimate causal connection between the dysp-
noea of croup and the changes referred to. He cites cases in which the
most marked dyspnoea is observed in children during life, without any
croupous membrane being found after death, and in which the ana-
tomical changes are out of proportion to the symptoms of stenosis;
he states that in more than one hundred cases of fatal croup among
children, he has been always able to find the false membrane in the
larynx, though, of course, more intensely and more widely developed
in some cases than others. But the single case to which I have just
referred, shows that a fatal dyspnoea may obtain without the presence.
of the slightest amount of exudation. This shows that even in true
* Wiener Med. Wochenschrift, Nos. 323, 324, 325, 1873.
166
A SYSTEM OF MEDICINE.
croup it is not necessary that the exudation must be the sole cause of
the dyspnoea, and we may reasonably believe that if we can control
the oedema and the spasm of the glottis, we may apprehend compara-
tively little danger from the exudate, unless its quantity be so great as
to completely fill up the larynx.
In one case, which I had the opportunity of examining through the
kindness of Dr. S. P. Hedges, the larynx was completely filled with
a tough, fibrous exudate, so that it would apparently have been im-
possible for the smallest quantity of air to enter. Indeed, it seemed
as if the exudate and laryngeal structures were simply one solid mass.
A therapeutic hint may be obtained here. The treatment undoubt-
edly should be directed more specially to the stenosis, with the pre-
sumption that it is the result of the cedema of the glottis and spasm
of the glottis rather than of the presence of the exudate. It is a well-
known fact that after tracheotomy the dyspnoea sometimes continues
as urgent as before, the larynx being then no longer a portion of the
respiratory apparatus.
Remissions.-These occur in those cases of croup which are char-
acterized by a moderate course. There are instances where distinct
remissions occur in the second stage. There is a marked improvement
in the dyspnoea, although it does not disappear wholly. There is also
a remission of the cough, the voice becomes more natural, and we find
an improvement in the general condition of the patient. The febrile
movement is almost entirely gone, and the appetite partially or wholly
returns, and there is a disposition to sleep. These remissions are very
favorable, especially when they are attended by an exfoliation of a
certain portion of the false membrane, which may be thrown off in
small masses mingled with mucus, or in irregular masses, sometimes
in the form of tubular casts of the part. If these exfoliations continue,
the remissions indicate that there will probably be a favorable termina-
tion of the disease, there is a longer period between the suffocative
spells, and the dyspnoea is markedly diminished. The cough grows
looser, and the expectoration of mucus, or a muco-purulent secretion
mixed with the flakes of fibrin, increases. The voice becomes less and
less hoarse, and the fever stops entirely, perspiration occurs, the patient
becomes more cheerful and natural, and the case turns into one of
simple laryngeal catarrh.
But many times these remissions are delusive; the suffocative attacks
occur after the remissions, being more severe than before. There is
now a fresh exudation occurring, or a spasm of the glottis or of the
laryngeal muscles which has given rise to it, and the dyspnoea is
increased through the special influences which are at work, and instead
of the remissions, we have a disposition to pass into the stage of
asphyxia, which is followed by a fatal termination of the case.
Glandular Enlargement.-It is only in those cases which are
DISEASES OF THE RESPIRATORY ORGANS.
167
characterized by considerable exudation into the pharynx that we have
enlargement of the submaxillary and cervical glands, and the existence
of albuminuria. We have already noted the fact that the exudate.
tends by preference to manifest itself mainly within the larynx itself
or its upper portion. It is in this class of cases, characterized by
albuminuria and pharyngeal exudation, that we find the difficulty in
drawing the line between diphtheritic laryngitis and true croup; but
for these cases, which are by no means the rule, it seems to us, there
would have been less confusion on this subject.
Pain. We are not able to determine whether there is much pain
connected with this disease. The child suffers so much from the
dyspnoea and discomfort that the clutching at the throat may mean
nothing beyond the besoin de respirer. Older children sometimes com-
plain of a soreness about the larynx and a sensation of squeezing or
pinching, and there is also a decided feeling as of a lump in the parts.
Gastric Symptoms.-We are not likely to encounter much dis-
turbance of the digestion unless it may result from the treatment.
Complications.-The most frequent complication is bronchial
catarrh, but the diagnosis of its degree is exceedingly difficult. It has
been found that the sibilant and sonorous rales, together with the
pronounced mucous sounds, disappear immediately after the perform-
ance of tracheotomy, indicating that the congestion was simply a
temporary one, due to the dyspnoea. In yet other cases, after a free
entrance of air to the lungs has been effected, the rales still continue
as a very prominent feature. In such cases a coincident bronchitis
has arisen from extension of the inflammatory process, and we may
assume the existence of fibrinous exudation in various portions of the
bronchi and bronchioles.
The explanation of Niemeyer (Ziemssen, vol. iv., p. 251) seems
hardly necessary. His view is that the pulmonary alveoli enlarge,
when laryngeal stenosis has obtained, without the entrance of a
sufficient quantity of air, thus resulting in the rarefaction of air con-
tained in the bronchi and alveoli. This rarefied air acts upon the
bronchial mucous membrane and upon the walls of the alveoli, just
as cupping does upon the skin, the result being congestion and in-
creased exudation from the blood vessels as the result of the diminished
pressure upon the walls of the vessels. To our mind, the extension of
the inflammatory process, as in other forms of catarrh, seems to be
all the explanation required. Pneumonia occurs less frequently as a
sequence of croup; when it exists, it may occur in the lobular form,
not so often as a lobar pneumonia.
Atelectasis may occur as a result of the asphyxiated stage of croup.
The portions of the lung involved are usually the lower and posterior
parts. Before death, their presence cannot be recognized readily by
physical examination, unless they should involve a large portion of
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A SYSTEM OF MEDICINE.
the lung, which is not usual. The less frequent complications are
pulmonary apoplexy and gangrene of the lung. It is doubtful if the
latter ever obtains in a case of true croup; the instances which have
been noted are undoubtedly the result of diphtheritic laryngitis.
Course and Termination.-Croup ordinarily runs its course in
from five to ten days. The severest cases of the fulminant variety
may terminate fatally in from twenty-four to forty-eight hours. The
full duration is from four to six days. Instances are on record in
which the continued exudation of false membrane on the mucous
surface of the larynx and bronchi continued for several weeks.
Pathology. In the first stage of the disease, the main feature is
an intense hyperæmia with its ordinary accompaniments. The mucous
surface of the larynx is of a bright-red color, and is considerably swollen
and puffy. The exudate varies from a very thin pellicle to a thick,
firm, tenacious false membrane, which may entirely block up the
larynx. Its color is a yellowish-white, sometimes brown or gray; it
may be blackened from extravasation of blood; the transudation of
blood may be sufficiently extensive to render it, in some instances,
blood-streaked, or dotted with small clots. The exudate is but loosely
adherent to the mucous surface, and may be readily detached; in other
instances its attachment to the mucous surface is much more firm.
It, however, has not the tendency of the diphtheritic exudate to
extend into the mucous tissue, involving the mucous and submucous
structures.
While, as we have already said, this anatomical difference does not
warrant us in assuming its non-identity with diphtheria, it is, notwith-
standing, a decidedly important link in the chain of evidence. The
disposition of the exudate is to extend downwards rather than upwards.
The early writers divide croup into the ascending and descending, and
it is admitted that the tendency is manifestly downwards.
It is easy to understand how quickly the dyspnoea may be increased.
by the presence of the exudate in the bronchioles; even if the amount
of membrane in the larynx should not be extensive, the cutting off the
entrance of air to the alveoli, by the filling up of the bronchioles, adds
promptly and effectively to the amount of dyspnoea.
The vocal cords are specially prone to be the seat of the exudate.
A moderate amount of exudation at this point, therefore, the subglottic
space being quite free, may induce dangerous asphyxia. The inner
surface of the epiglottis is generally also involved to a marked extent.
The tendency of the membrane is to re-form, which constitutes one of
the discouraging and dangerous features of croup. After the first
exfoliation of the membrane in flakes or threads, or masses of consid-
erable size, a second formation occurs, and even a third. How much
this re-formation is influenced by the active methods of treatment,
DISEASES OF THE RESPIRATORY ORGANS.
169
locally and internally, which have been in use, is yet difficult to
determine.
Microscopically, the exudation is found to be made up of amorphous
or fibrillated fibrin with numerous young cells. Chemically, it is
shown to be coagulated fibrin, soluble in alkalies, and particularly in
lime-water.
Diagnosis. The early diagnosis is attended with difficulty. It is
impossible to designate true croup from a severe case of infantile
laryngitis, or false croup, until the exudation has unmistakably
appeared.
The difficulty of laryngoscopic examination in children is much to
be deplored, for if a view of the larynx could be obtained, an early
and positive diagnosis could be made. Some of the cases of infantile.
laryngitis, as in the one already referred to, unfortunately present
symptoms which render their differentiation from true croup entirely
impossible. On the second or third day it is usually possible to make
the diagnosis with accuracy, if careful attention is paid to all the points.
One prominent diagnostic feature is, that in pseudo-croup there is a
much greater amenability to treatment; there is not, usually, so strong
a disposition to the continuance of the dyspnoea; it is not so intense.
nor so prominent. In false croup the febrile movement is more readily
controlled; there is not as much hoarseness, the voice is not as fre-
quently lost, nor as rough and harsh. Instead, also, of tending to
grow hoarse on the second or third day, false croup is ameliorated, as
a rule, on the second night, and largely disappears upon the third.
The steady progress of the symptoms from the first should incline us
to apprehend that we are dealing with a case of true croup.
In false croup, the suffocative attacks do not occur so often and are
not so severe. Parents, and even physicians, often say that they have
had children affected with several attacks of true croup; undoubtedly,
such cases are those of severe infantile laryngitis without any exudation
whatever.
It may be mistaken for oedema of the glottis, but if we note carefully
the history of the case, and make a thorough examination, we can
usually settle the diagnosis. Palpation, which can always be employed
before the case has progressed far, will put us upon the right track.
Spasm of the glottis is more likely to be confounded with this affection,
but its convulsive nature enables us to distinguish it. Between the
paroxysms the child is perfectly well; there are no croupy sounds, no
hoarseness, no stridor. In most instances there is not in croup, or at
least only very occasionally, a tendency to spasm of a carpo-pedal
form.
Foreign bodies in the larynx induce symptoms which greatly re-
semble croup. The child is taken with sudden stridor and dyspnoea,
together with hoarseness and a sense of obstruction to respiration. In
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A SYSTEM OF MEDICINE.
these cases, also, the history usually enables us to make a diagnosis.
We have already given the points of diagnosis between laryngeal
diphtheritis and true croup.
Injuries of the larynx and morbid growths of the larynx give rise
to croupy symptoms, but the diagnosis of these affections is generally
rendered easy by examination.
-
Prognosis. True croup is an exceedingly fatal disease. The
fatality ranges from 23 to 75 per cent. There are cases which seem to
resist, from the start, all treatment, however carefully and judiciously
applied. With the evidence which we have of its deadliness, the state-
ment of Cohen, since he has used the treatment of inhalations of steam
in a hot room, should be carefully noted.
We cannot believe that healthy, robust children succumb as readily
to the disease as do the feeble. Our view is emphatically that it is
a disease of scrofulous children, that the strong and robust bear the
brunt of it much more readily, and afford more hope of relief from
treatment. A careful analysis of cases treated will show that the
children attacked who were, before, subject to enlarged glands and
other manifestations of scrofulosis, succumb almost surely.
The tendency to a fatal termination is increased by the occurrence
of complication. If we have bronchitis or pneumonia supervening,
the danger is greatly intensified. Even when the membrane is con-
fined largely to the larynx, there is but a slight prospect of recovery,
though, of course, it is better than if the membrane extends above
or below. There is little hope when we find severe and continued
dyspnoea with suffocative attacks occurring often, febrile movement
high, and the stenosis marked, and stupor present, in a greater or less
degree, with an intermittent pulse.
During the stage of asphyxia, it is generally the course for three
paroxysms of collapse to occur. This clinical feature gives us an
indication for tracheotomy which should be promptly employed after
the first attack of collapse. The patient will rally from this under the
use of a small amount of stimulant, and then the operation can be
performed.
Exudation. If there is any exudation on the pharynx, which my
experience demonstrates to be somewhat rare, the true nature of the
disease is certain; but the exudation is usually out of sight, and tends
to extend downwards, and to involve the trachea and bronchi even to
the bronchioles, and all know the difficulty of laryngoscopic inspection
in children. With a little tact, the use of the mirror in the throat
with a strong direct light may be effected in some instances; such an
examination will readily show the exudation. If not seen, its presence
may be assumed from the history and symptoms, and, later, we have
the expulsion of the membrane in flakes or casts. The larynx, trachea,
and bronchioles have all been implicated, as post-mortem examinations
DISEASES OF THE RESPIRATORY ORGANS.
171
have shown. Sometimes only inspissated mucus is thrown off for a
while. If inspiration and expiration are equally affected, we may
assume the presence of adventitious membrane; if, however, inspiration
is difficult, and expiration easy, we have merely a paralytic state of
the glottis.
Varieties.—The form of simple croup, which has no exudation, is
very common in America. The child may present the phenomena of
true croup. After exposure to cold, having been somewhat restless,
it awakens suddenly in the night in a high fever and with a hoarse,
ringing cough; some dyspnoea exists, which may be, later, quite ur-
gent. The attacks usually subside quickly; the next day the child is
well, though it may cough occasionally. At night another paroxysm
occurs, but is generally lighter; exceptionally, it may be more severe.
The third night, there is a slight attack, which generally ends the dif
ficulty. Many cases end with the attack upon the first night.
This form is much more amenable to treatment than true croup, and
the tendency is readily to improvement. True croup grows worse
steadily, and lasts from five to eight days longer. There may be such
urgent symptoms that a fatal termination may occur in twenty-four
to forty-eight hours.
Treatment.-Aconite.-In the early stages, with high fever, restlessness, toss-
ing about; it will cut short the attack. It is a specific for croup without exudation,
and very serviceable in membranous croup. It limits the amount of exudation by
moderating inflammatory action at first. Homœopathists do not always realize how
many pathological lesions are aborted by the prompt administration of our remedies.
Arsenicum is not often enough given in croup, for pale face and restlessness, in
cases occurring in debilitated children. A pathological explanation of its effect may
be found in the fact that it reduces the cedema glottidis which is, as we have seen, one
special element in the production of dyspnea.
Bromine.-Aggravation in spite of Aconite and other remedies; dyspnoea
marked; cough dry and wheezing; expectoration scanty, though there is rattling in
the larynx on coughing.
·
Hepar sulph.-Feeling as if there were a foreign body in the larynx; stitch-
ing pains from ear to ear; febrile movement marked; loose cough, but no expectora-
tion; hoarse, rattling cough, with croupy ring; inspiration difficult; expiration easy,
making the general respiration attended with comparatively little difficulty.
Iodine relieves urgent dyspnoea and tends to lessen exudation. The cough loose
and hoarse in the morning; free expectoration of mucus, sometimes blood-tinged; also
indicated in fibrinous exudations; increasing hoarseness and a tendency to stupor;
great restlessness.
Kali bichrom.-Great sensitiveness of the larynx; especially adapted to fatty
children; voice very hoarse; cough constant. This remedy offers the most hope of
effecting the removal of the membrane; it corresponds to the pathological basis of the
disease; it has a tough, stringy expectoration. In diphtheria it effects the removal of
the same morphological elements better than any remedy; the exudation of membra-
nous croup corresponds closely to that of non-malignant diphtheria.
Phosphorus.-Useful when the exudation extends to the finer bronchi; this
remedy hastens its absorption; there is much prostration of the nervous system.
Spongia.-Dry, harsh, crowing sound, usually indicated earlier than Hepar,
Sulph., or Kali.
Sanguinaria.-Indicated by dryness of the throat, with feeling of fulness in
the larynx, followed by the expectoration of thick muens; cough steady and severe,
then followed by mucous sputa; loss of voice, and exceedingly hoarse cough.
172
A SYSTEM OF MEDICINE.
Tartar emetic.-Hoarseness, worse in the morning; cyanosis, cold perspira-
tion, frequent pulse; secretion very tough and not readily expectorated; useful in the
later stage, when there are coldness of the surface, mucous rales in the larynx and
chest, great prostration and dyspnea.
Ipecacuanha is of great service when the disease is complicated with bron-
chial catarrh. There is a convulsive evening cough; free secretion of mucus in the
bronchial tubes, which threatens suffocation.
Bryonia is useful in the complications when there is sub-sternal pain, sensation
of roughness in the trachea; dry or hoarse cough, at first without, afterwards with, free
expectoration of mucus.
Consult also Kaolin, Belladonna, Causticum, Lactic acid, Lycopo-
dium, Drosera, and Carbo veg.
Prophylaxis.-Bathe the throat, neck, and chest with cold salt
water; don't house the child too tenderly.
Local treatment.-Inhalations of steam with the atomizer are
far preferable to the hot room and the surcharging of the air with.
steam, which is recommended by some authorities. The object of
these measures is to reach the exudation. It is said that experiments
demonstrate that but a small quantity of the medicament used in the
atomizer reaches the bronchi, but by directing a suitable apparatus
towards the fauces of the child the requisite quantity of steam can be
inhaled. Our main reliance should be placed upon the remedies. It
must be confessed that the expulsion of the membrane has occurred
after efforts at internal medication had ceased; therefore we should
not abandon hope until the last. The inhalation of slackened lime,
as proposed by Dr. Geiger, is an experiment worthy of trial. Bromine
inhalations, after the formula of Ozeanam, one drachm of Bromide of
Potassium, one grain of Bromine, and one ounce of water, exercises a
salutary effect upon the dyspnoea. A few drops of the Tincture of
Iodine on a sponge in the bottom of a tumbler, placed near the nos-
trils, will sometimes rally the child when other expedients have
failed.
Solis Cohen, of Philadelphia, claims to have saved every case of
membranous laryngitis since he adopted the method of inhalations of
steam in a heated room. His plan is to place the patient, after it is
manifest there is an exudation, in a closed room heated to a tempera-
ture of eighty degrees, which should be constantly maintained without
intermission until the child is out of danger. The room is then sur-
charged with moisture by hanging pieces of cloth or towels, wet with
hot water, about the room. The water is placed upon the stove or
grate, and by the placing of hot flats in pans of water, sufficient steam
is generated to produce a considerable degree of moisture. It is
claimed that by this process the exudate is softened and finally
exfoliated.
DISEASES OF THE RESPIRATORY ORGANS.
173
C. DISEASES OF THE TRACHEA AND BRONCHIA.
BY JOSEPH SIDNEY MITCHELL, M.D.
BRONCHITIS.
Definition.-Bronchitis is an inflammation of the mucous mem-
brane lining the bronchial tubes, varying in degree from slight hyper-
æmia to an intense implication of the deeper structures.
The Synonyms are bronchial catarrh; angina bronchialis; ca-
tarrhus pituitosus; bronchite; Bronchialentzündung.
Varieties. There are two prominent forms, the catarrhal and the
croupous; each may be acute or chronic. The catarrhal occurs as
trachea-bronchitis or capillary bronchitis.
Acute Catarrhal Bronchitis.-Etiology. As regards age, it
is more commonly met with in the young and old. This is due to
the diminished vitality which exists at these periods of life. In the
acute forms it is specially prevalent during the period of dentition,
and in the chronic it is notably a disease of advanced age.
It may be secondary to other diseases. Debilitating diseases which
weaken the constitution, such as tuberculosis, Bright's disease, carci-
noma, diabetes, emphysema, and bronchiectasis, favor its onset.
Habits. Civilization, with its furnace-heated rooms, has done.
more to predispose to bronchial affections than any other cause. It
induces a debilitated, relaxed state of the system, a disposition to easy
prostration, and reduces the resisting power towards atmospheric
changes which is possessed by those whose habits of life inure them
to marked temperature vicissitudes. One attack. renders the system
much more liable to another, and it becomes natural for those thus
affected to suffer frequent attacks every year.
Occupation. Those who are exposed to the inhalation of irritating
substances, as wood filings, steel and iron filings, cotton, etc., or the
vapor of gases, are susceptible, while those whose business involves
exposure to atmospheric changes, contrary to the view expressed by
some authorities, are but little subject. Soldiers, sailors, artisans of
various kinds, whose occupation is out of doors, are seldom troubled
with cough.
Climate. Bronchitis is a disease of climates marked by sudden
changes of temperature combined with considerable moisture. Hirsch
says it is due more to humidity than to change of climate, instancing
the fact that upper and lower Egypt and western America and India
are exempt. England, and those portions of America which are situ-
ated upon the seacoast or along the shores of the great lakes, render
their inhabitants prone to the disease from the bleakness and damp-
ness of the atmosphere.
174
A SYSTEM OF MEDICINE.
Season. It is essentially a disease of the cold months of the year,
especially when there is humidity of the atmosphere, as in the spring
and fall. On the seashore or along the lakes the prevalence of north-
east or easterly winds is very conducive to bronchial attacks.
Sex has little modifying influence. Women whose lives are spent
indoors are rather more frequently attacked. The mortality tables,
however, bring the numbers for the two sexes very nearly equal.
Exciting Causes.-Exposure to cold and dampness is usually
the immediate exciting cause of bronchitis in the acute forms. The
attack may be induced from the inhalation of cold air or by the ap-
plication of a cold draught upon the back, especially also by insuffi-
cient clothing in cold weather. Exposure of portions of the body,
particularly of the feet, to cold and wet, sleeping in damp beds, and
putting on damp clothing, all these are well-known causes. It is
very probable that a depressing influence is effected upon the spinal.
nerves, which lowers the tone of the bronchial mucous membrane,
secondarily inducing a local irritation, followed by congestion and
inflammation. Cold applied to the chest in front will not induce
bronchitis as certain as cold directed against the back. Various irri-
tants act directly upon the mucous membrane lining the bronchi as
exciting causes. Prominent among these are the irritating gases,
powders, such as Ipecacuanha, and emanations from other vegetable
substances, wood, dust, iron or steel filings, flour, etc. Doubtless
miasma acts in the same way.
The circulation of morbid blood gives rise to bronchitis. Iodine,
taken internally, has been known to induce bronchial catarrh from its
circulating through the capillaries and acting as an irritant.
Influenza, either sporadically or epidemically, has a marked influ-
ence. To this cause we may assign the cases which complicate the
febrile affections, particularly typhoid fever, scarlatina, measles, small-
pox, whooping-cough, diphtheria, syphilis, gout, rheumatism, and
erysipelas. The suppression of long-continued discharges and of
long-standing skin diseases by local application produces a metastasis
which may result in bronchitis. Deposits in the lungs, such as tuber-
cle or cancer, by giving rise to the presence of vitiated blood, act as
an exciting cause of inflammation of the bronchial mucous mem-
brane.
Symptoms.-Attacks of acute bronchitis vary to a marked extent
from slight colds affecting the trachea and large bronchi to those in-
volving the whole bronchial system, making the disease exceedingly
grave. In the form now under consideration the attack is ushered in
by rigors of greater or less intensity rather than by a single prolonged
chill; following this we find febrile movement; the patient feels hot,
but there is only slight elevation of the temperature. The pulse may
early be somewhat increased, but it is characteristic of even acute bron-
DISEASES OF THE RESPIRATORY ORGANS.
175
chitis that it is not attended with a high pulse or temperature. There
is muscular rheumatism, manifested by pain of an aching character
throughout the whole system; the joints even may be somewhat
affected. There is a sense of fatigue and of general malaise. In the
severer forms there is furred tongue, loss of appetite, and sometimes
vomiting, complicating the bronchial catarrh; the urine is loaded with
urates, but presents a diminished amount of chlorides; there is heat
on micturition.
We have implication of the mucous membrane lining the nares and
other communicating sinuses. The pharynx and larynx are generally
involved. There is an irritating watery discharge from the nose and
eyes, heat and soreness with frequent sneezing. Frontal headache of
a throbbing character exists, due to the implication of the frontal
sinuses. There is some sore throat and accumulation of mucus, of a
tenacious character at first, afterwards easily detached. Owing to the
laryngeal complication, the voice becomes hoarse, husky, and there is
cough of a laryngeal character, hoarse and barking. Some cases of
bronchitis are ushered in by a catarrh of the nares, followed by an
extension along the respiratory tract, the pharynx being involved;
then the larynx and, lastly, the bronchial mucous membrane. In
other instances the bronchial surface may be involved from the very
first, and these other regions escape. There are various subjective
symptoms noticeable, such as sense of heat or burning in the sternum,
or a feeling of rawness or soreness with a moderate amount of pain.
Ordinarily, in bronchitis pain is inconsiderable; when it exists, it is
aggravated by deep inspirations. From severe persistent coughing,
aching may be developed throughout the chest and sides, and particu-
larly about the abdominal muscles.
Cough. This is one of the first and most marked symptoms. If
the larynx is involved, it will be hoarse; usually, however, the laryn-
geal implication lasts but a short time, and then the cough is free from
hoarseness. It may be spasmodic or occur irregularly. It may be
easily controlled or, in nervous irritable people, difficult of suppres-
sion. Many times it is severe on first lying down at night, and again
on wakening in the morning.
Cough, from the experiments of Longet, was found to be excited by
irritation of the bronchial mucous membrane, and Cruveilhier, Rom-
berg and Budge excited cough by irritating the pneumogastric. J.
Rosenthal considered the superior laryngeal nerve as the special nerve.
of cough, inasmuch as he observed relaxation of the diaphragm, with
simultaneous constriction of the glottis, and spasmodic contraction of
the expiratory muscles on irritating the inner branch of that nerve.
Nothnagel has made an important advance in our knowledge of
cough, proving by actual experiment that cough may be excited by
irritation of the tracheal and bronchial mucous membrane, and that
176
A SYSTEM OF MEDICINE.
not only does the superior laryngeal nerve act as a nerve of cough, but
that there are fibres situated still further backwards in the pneumo-
gastric nerve at its terminal extremities in the mucous membrane of
the trachea, which excite the reflex act of cough when considerably
irritated. But Nothnagel was unable to excite cough by irritation of
the pleura, or irritation of the intact branch or central stump of the
pneumogastric or superior laryngeal nerve. Kohts demonstrated that
irritation of the posterior pharyngeal mucous membrane, as well as of
the inner surface of the soft palate, produced one or two successions of
cough, while it only rarely caused continuous cough. Intense cough
ensued both upon mechanical and electrical irritation of the pharyn-
geal nerve, and the cough following powerful pulling of the nerve
amounted to a veritable paroxysm. Pulling or pinching the œsopha-
gus also succeeded in exciting cough.*
From these experiments we see that direct irritation of the tracheal
and bronchial mucous membrane is a constant exciter of cough, but that
irritation of the pneumogastric or superior laryngeal does not always
induce it. Clinically, however, we are aware that some of the most
constant, prolonged, and spasmodic coughs are those due to reflex irri-
tation. At first the expectoration is comparatively slight, the cough
being hard and dry; later, we have an altered secretion, the expecto-
ration early being thin and watery and of a saltish taste; later, it
grows more and more opaque, increasing in thickness, becoming more
viscid and less frothy; it may be mucous, muco-purulent, or purulent.
It is at first white, afterwards of a grayish-yellow, or yellowish-white.
Sometimes it is expectorated with ease, again it is adhesive, stringy
and ropy; ordinarily it has no blood, but a few flecks of blood may
be seen, and sometimes it may be streaked. By the microscope it is
shown to contain pavement, columnar, and ciliated epithelium; after-
wards, abundant young cells from the surface of the mucous membrane,
and later pus-cells, molecular and granular matter are present, a few
blood-corpuscles, amorphous matter, crystals of oxalates, and choles-
terin.
Course and Termination.-Usually, this form terminates in from
three to five days without leaving any trace of its existence. The
fever, if present at first, soon subsides, and the cough gradually dimin-
ishes; this latter symptom, however, may remain for several days after
all other symptoms have passed away. In rare cases the disease may
continue for two or three weeks, and the cough be very persistent and
stubborn, in some instances remaining as a chronic affection, especially
in cases in which the tissues were deeply affected.
In the debilitated or in the aged, fever may be present from the first,
with rapid feeble pulse, dry, brown, cracked tongue, and some delirium.
These patients are not always able to expectorate, and the secretion
* Ziemssen, p. 278, vol. iv.
DISEASES OF THE RESPIRATORY ORGANS.
177
collects, blocking up the bronchi, and leading in some instances to
suffocation. In delicate children bronchitis, for similar reasons, some-
times proves a very serious affection.
Capillary Bronchitis.-An inflammation involving the mucous
membrane of the smaller bronchioles, attended with profuse secretion,
and often causing suffocation. It is particularly a disease of children.
Old people and debilitated people are also subject to it. Some cases
seem to result from the form of bronchitis just described by extension
of inflammation, while others show that the whole respiratory tract is
involved from the beginning. There are cases in which the disease
seems to commence as an affection of the smaller tubes. The early
symptoms are those of the form already described. If the capillary
tubes alone are involved, there is an absence of the sub-sternal pain.
Children, however, always complain of more or less aching and sore-
ness about the base of the chest. Epigastric pain, due to the severe
contraction of the expiratory muscles, is also present. There is much
more difficulty of breathing than in the form already described, and
it is always proportionate to the amount of impediment. There are
two sources of dyspnoea, one the swelling of the bronchial mucous
membrane, and the other the secretion. In mild cases it may be
moderate, but when there exists an extensive implication of the bronchi
it increases to a severe degree, and suffocative attacks with cyanosis
ensue; the children are unable to breathe unless they are raised;
they are exceedingly restless, tossing about continually; the nostrils
dilate; the thorax is hastily elevated as in laryngeal stenosis; inspira-
tory retraction may take place upon deep inspiration, the number of
respirations may rise to fifty, or more. During ordinary inspiration
the epigastrium and hypochondrium are distended, and retracted
during expiration; when an ample quantity of air can enter the lowest
portions of the thorax, these parts undergo inspiratory distension;
when a sufficient quantity of air cannot enter, the condition is differ-
ent, the increased capacity of the chest not being supplied with a due
amount of air, the air which enters becomes rarefied at each inspira-
tion; hence the pressure of the atmosphere upon the epigastrium and
hypochondrium depresses these parts and forces up the diaphragm.
According to Sitz, there is another indication of incomplete breathing,
which is the bulging forward of the superior clavicular and infra-
clavicular regions, and the indistinctness of respiratory movements in
this section of the thorax is due to distension of the lungs from bulg-
ing of the alveola from the impediment offered to the egress of air.
The cough is violent and distressing, occurring in paroxysms, or
being continuous. It is usually dry for a short time only, then it be-
comes exceedingly loose, but is attended, particularly in the cases of
children, with little expectoration.
VOL. I.-12
178
A SYSTEM OF MEDICINE.
Expectoration.-This is ordinarily effected with difficulty in any
case, as the secretion is tough and tenacious in the early stage. At
first, it is small in quantity and thin; after a time it becomes copious
and less sticky in those old enough to expectorate. It is, at first, mu-
cous, afterwards becomes muco-purulent, growing richer in cells. It
is usually yellowish-white, and sometimes presents the appearance of
foam, from which thin threads hang down below the surface. The
former portion of the mass comes from the larger tubes, and contains.
a mixture of bubbles of air, while the threads come from the minute
bronchi, retaining their form. Children usually swallow the expecto-
ration, which, after a sufficient amount has accumulated in the stom-
ach, may give rise to vomiting; its characteristics are then, of course,
somewhat changed. Often, during the act of coughing, the child may
be thrown forward, and a quantity secured upon a cloth.
The febrile movement is usually much more marked than in ordinary
acute bronchitis, but it does not tend to be as high as in pneumonia.
It is important in this connection to note the difference in tempera-
ture, which is diagnostic of lung-inflammation, as compared with
bronchitis. By careful observation of the temperature we are enabled
to note the transition from most extensive capillary bronchitis to
broncho-pneumonia. The increased temperature which takes place.
may be readily noted. A comparatively circumscribed pneumonitis
will give rise to a rapid elevation of temperature much more rapidly
than even a diffuse bronchial catarrh. If this diagnostic point were
more closely noted, fewer errors would be made. But capillary bron-
chitis may have a temperature of at least 104° without the existence.
of pulmonic complication. (Ziemssen, vol. 4, 373.) The pulse is rapid,
reaching from 100 to 140, being at first full and firm, later small. The
skin is hot and dry in the beginning of the disease, but when it is.
fully established there is a tendency to profuse perspiration. The cya-
nosis is a marked feature, varying very much in degree with the extent
to which the bronchi are involved; those cases in which there is very
much oedema, with copious secretion, give rise to it in marked degree.
Cerebral symptoms are not present; that is, they do not belong to
capillary bronchitis. When catarrhal pneumonia has supervened, we
may have delirium manifested.
Gastric disturbances are common. Anorexia, coated tongue, and
sometimes vomiting occur. There is constipation at first, and later
diarrhoea. The urine is sometimes slightly albuminous and deficient
in chlorides; a trace of sugar is said to be occasionally present. In
the severer grades defective aëration of the blood is observed, the
respiratory process is insufficient, and gradual suffocation ensues.
The blood is charged with carbonic acid gas, and its oxygen is corre-
spondingly deficient, the cyanosis deepens, the face is turbid, bloated,
dusky, or livid. The lips, tips of the nose, malar protuberances,
DISEASES OF THE RESPIRATORY ORGANS.
179
tongue, and ears are very livid, and in marked contrast with the pallor
of the surrounding skin; the veins of the head and neck swell. The
fingers and toes, especially the nails, show also the cyanosis; the feet
and hands may become œdematous. The temperature falls, clammy
sweats break out, particularly about the face, and then involve the
whole body. The patient is exhausted, the head drops about in any
direction. The pulse is very rapid, weak, small, compressible, and
often irregular. The patient is restless; there is an anxious expression
of countenance, which continues until the mind begins to wander, and
the patient grows dull and apathetic, falling into a drowsy state, then
a stupor, and finally a complete coma ensues, which precedes death.
In some children there may be convulsions. The cough is not severe,
and no attempt is made at expectorating; the breathing is very rapid,
and gradually grows more shallow. Bronchial rales are plainly aud-
ible, and as the large tubes become filled there is distinct crackling.
Death occurs either from blocking up of the large bronchi suddenly, or
from extensive pulmonary collapse, congestion giving rise to cedema, or
from lobular or lobar pneumonia. In old people the symptoms are
those of adynamia: the tongue is dry and brown, or it may be thickly
covered with dark fur; the pulse is very frequent, irregular, and fine.
Acute delirium may ensue, followed by stupor or profound coma;
prostration is excessive, and the extremities are cold; the excessive se-
cretions block up the air-passages, giving rise to carbonic-acid poison-
ing, and there is paralysis of the muscular fibres of the bronchi, which
gradually induces slow suffocation.
Duration and Termination.--Capillary bronchitis lasts generally
four or five days, or it may continue three or four weeks. The fatal
cases occur, according to the best authorities, from the sixth to the eighth
day in children, and from the tenth or twelfth in adults. Relapses are
not common, but it is a disease which is very liable to recur. It is
regarded by some authorities as the foundation of certain forms of dis-
ease. Niemeyer believes that excessive acute bronchial catarrh is the
most common cause of "galloping" consumption. We incline to the
belief that no form of bronchitis will lead to phthisis, unless there is a
dyscrasia previously existing.
Physical Signs. In the acute catarrhal form, inspection shows
the size of the chest but little altered, except as regards the bulging to
which Sitz referred. The respiratory movements are seen to be much
more rapid than in health, and are dependent upon the amount of
dyspnoea. We have already referred to the inspiratory retraction.
Palpation gives usually the rhonchal fremitus, varying very much in
degree and extent. It is, in most cases, felt over a large area. The
presence of this fremitus shows that the superficial tubes are affected,
and it is heard with both inspiration and expiration. It may be va-
ried by coughing, or entirely disappear after coughing.
180
A SYSTEM OF MEDICINE.
Percussion.-Percussion gives no significant signs. There is little
variation from normal resonance unless we have complications. There
may be a slight amount of dulness at the base of the lungs posteriorly,
owing to large accumulations of secretions, oedema of the lungs, or
collapse, or from a coincident catarrhal pneumonia. If there is an
emphysematous condition, the resonance is increased.
Auscultation.-We have a weakened respiratory murmur over
the affected parts, or the sound may be totally suppressed, according
as the secretion effects the more or less complete closure of the tubes
or the thickened mucous membrane diminishes the calibre. Where
the bronchi are pervious, the sounds are loud and exaggerated. This
is particularly true of the upper portions of the thorax. But the char-
acteristic sounds of bronchitis evidenced by auscultation are the rales.
While their absence does not indicate that there is no inflammation of
the tracheal and bronchial mucous membrane, their existence is conclu-
sive evidence of the disease. They are commonly divided into the dry
and moist; the former are the sibilant, which are high-pitched, hissing,
whistling, or musical; and the sonorous, which are low in pitch and.
gruff in tone, like snoring. The sounds are produced according as the
air passes through tubes of larger or smaller calibre, the sibilant result-
ing from the passage of air through the constricted smaller tubes, and
the sonorous from its passage through the large tubes, diminished in
calibre from either of the above-mentioned causes. The moist rales
indicate that secretion has taken place. They may be heard during
inspiration and expiration, sometimes being most audible only during
inspiration; they may be fine or coarse, and they are sometimes termed
mucous, sub-mucous, and sub-crepitant. These rales vary in size,
quality, and pitch according to the amount of secretion and its consist-
ency, and the dimensions of the tubes. In the different forms of
bronchitis they are variously combined. In a moderate degree of
acute bronchitis we hear at first only a few sibilant or sonorous rales
at scattered points, followed by the moist rales somewhat coarse.
Their diffusion pretty generally over the chest indicates a rather diffuse
bronchitis. In capillary bronchitis we have some greater amount of
diminution in the percussion. note at the posterior and lower part
of the thorax, while there may be a considerable increase in the infra-
clavicular region. We have also on auscultation an abundance of fine
moist rales. These accompany both inspiration and expiration, and
usually destroy the respiratory murmur in the lower portion of the
chest. Vocal resonance is not usually affected.
Position of the Organs.-Usually they are normal. The lungs
may
be gradually distended, in which case the diaphragm is depressed,
and the liver and spleen pushed downwards. The heart is said to be
pushed downwards and to the right, in some cases occupying a posi-
tion similar to that described by Niemeyer as occurring in emphysema.
DISEASES OF THE RESPIRATORY ORGANS.
181
Diagnosis.-Ordinary bronchitis is usually recognized without
much difficulty; the substernal pains, the oppression, and cough and
expectoration are significant, and physical examination, developing ab-
sence of dulness, or any alteration of the vocal fremitus or resonance,
and indicating the presence of the various rales, establishes the proper
diagnosis. We are sometimes in doubt, in the earlier stages, as to
whether the case is not one of the first stage of whooping-cough, but
the paroxysmal character of the attacks, and the peculiar cough and
expectoration often followed by vomiting, are sufficiently distinctive
to soon determine the diagnosis. When laryngitis is present, as it
often is, there may be difficulty in differentiating from croup, but the
rapid diminution in the character of the hard, ringing cough, and the
presence of evidence of extension of the catarrh to the bronchi, as mani-
fested by the moist cough, presence of rales, etc., enable us to differen-
tiate it from this affection. Capillary bronchitis is to be distinguished
from pneumonia. We have no single prolonged chill, followed by the
intense fever which is characteristic of pneumonitis, but from the
lobular pneumonia of children the diagnosis is often difficult. Careful
attention to the physical signs will enable us to guard against error on
this point. In capillary bronchitis the rales are much more diffuse
and of larger size, while in lobular pneumonia they are limited to the
affected space, usually at the bases of the lungs, where they are irregu-
larly scattered. In lobular pneumonia we have more frequent respi-
rations and less dyspnoea, and not much tendency to cyanosis. From
acute phthisis, by careful attention to physical signs, we can differen-
tiate capillary bronchitis, which has no signs of consolidation. We
have only to distinguish it from true tubercle of the miliary form,
whose scattered exudations do not show us consolidation, but rales
more or less separated and in the upper portion of the lung. The
marked febrile movement of tuberculosis aids in the diagnosis.
Pathology. The catarrhal inflammation of the mucous membrane.
lining the bronchial tubes is the characteristic lesion. The hyperæmia
may be of various forms, arborescent, mottled, streaked, punctated,
diffuse, or covering small areas. It does not usually extend over a
large surface. The color of the membrane varies from a bright red
to a dark venous hue.
The congestion does not usually extend beyond the fourth or fifth
divisions, but it is said that even the finest ramifications may exhibit
it. The view is held by some writers that there is not, in capillary
bronchitis, an intense congestion of the smaller tubes, but that their
implication is the result of the secretion from the larger tubes running
down, aggravating and causing trouble mechanically by their presence.
The mucous membrane is infiltrated from the inflammatory exuda-
tions, and these may extend even to the submucous tissue. This is
one of the great sources of danger in capillary bronchitis. The bron-
182
A SYSTEM OF MEDICINE.
chioles may be completely obstructed, the tissues are relaxed and
softened, and there may be epithelial abrasions, but never ulceration.
At first there is a dryness of the mucous surface, later secretion occurs;
this consists of frothy mucus, which has a mixture of cells, giving us
the muco-purulent expectoration; sometimes more or less blood is
present. Microscopically, the secretion consists of epithelial cells,
some perfect, others in various stages of degeneration, the so-called.
mucus and exudation corpuscles, pus-corpuscles, a few blood-disks,
and granular matter.
Atelectasis is sometimes observed as a result of the blocking up of a
tube. Bronchiectasis may also exist, but only to a small extent, the
tubes being uniformly dilated. Sometimes the lobules may become.
emphysematous. Lobular pneumonia may exist as a complication,
but post-mortem examinations often show extensive capillary bron-
chitis without a single lobule being affected. The lungs may be hyper-
æmic and œdematous, and sometimes paler than normal. In children
the bronchial glands are found enlarged, hyperæmic, and soft. The
right side of the heart may be overcharged, giving rise to dilatation,
which is manifest, if sufficiently marked, by percussion. Examination
reveals that the disease may be very varied in its extent, sometimes
one lung being involved, sometimes both; different portions of the
lung are also affected in different degree.
Varieties.-Bronchitis may occur in connection with the exanthe-
mata. Typhoid fever and measles are most likely to be attended with
this affection, in which case it comes on insidiously. It is sometimes
necessary to ascertain the presence of this form through physical
examination of the chest at frequent intervals, there being so little
cough or expectoration. In some instances the bronchial attack is
very marked and of little import, but in others it may be so extensive
as to form a very serious complication, tending to a fatal result. Sec-
ondary bronchitis may be the result of poisonous material in the
blood, such as urea in Bright's disease, sugar in diabetes, or uric acid
in gout, the secretions from deposits in the lungs, such as tubercle
and carcinoma. The disease in these cases may come on insidiously
without very marked symptoms, and become settled; but these forms,
being chronic, will be further considered in connection with chronic
bronchitis.
Prognosis. Acute catarrhal bronchitis usually terminates favor-
ably. In cases where a large extent of mucous membrane is involved,
it may prove quite serious. In healthy adults the tendency is rapidly
towards recovery; in the very old there is danger, and the prognosis
is grave when there are signs of typhoid fever, low febrile movement,
with an expectoration which is thick and tenacious, accumulation of
secretion in the bronchi, and inability to cough from muscular weak-
ness. Quick, shallow cough is of ill omen in children. With capil-
DISEASES OF THE RESPIRATORY ORGANS.
183
lary bronchitis the prognosis is grave according to the extent of tissue.
involved. If the pulse becomes very frequent and feeble, and cyanosis
is persistent, with coarse bubbling rales very extensively diffused, and
very great prostration with cold extremities and cold perspiration, we
should consider the case as likely to prove fatal. If the bronchitis is
complicated with other affections, such as pneumonia, pulmonary
oedema, emphysema, pleuritis or cardiac troubles, the danger is very
much increased.
Treatment.
Aconite. In the early stages, particularly from taking cold,
with checked perspiration, fever high, skin hot and dry, and great restlessness. The
cough is dry, excited by tickling in the larynx or trachea, aggravated by smoking
and drinking, or at night. Expectoration slight but frothy, and sometimes blood-
tinged.
Arsenicum.-Hard, spasmodic cough, attended with burning in the chest, and
excited by sensations of smoke or vapors; dysphagia and dyspnoea, with prostration
and great exhaustion; aggravation after drinking and during motion. Expectoration
difficult, scanty and profuse; it is saltish, and at times blood-streaked.
Belladonna.-Hot, dry, spasmodic congh, particularly at night; skin hot and
moist; expectoration not considerable, and either of mucus or bloody mucus, and most
profuse in the morning.
Bryonia.-Racking cough, with substernal irritation; dyspnea; pleuritic
stitches, worse at night, and aggravated by motion; spurting of urine when coughing;
expe toration scanty, yellow mucus or pure blood, and sometimes attended with vom-
iting.
Cactus. Specially indicated in cases originating from cardiac troubles, with
suffocation and palpitation of the heart; sensation as of an iron hand preventing
movements of the chest. (As the symptom "sensation as of an iron hand" is some-
times questioned, the following case may be noted: Mr. T., a patient lately treated by
me, a strong hearty man of fifty, attacked with bronchitis and rheumatic muscular
pains about the chest, described this symptom accurately.) The cough is spasmodic,
the sputa yellow, thick, and tenacious.
Calcarea carb.-Especially in scrofulous children with constant cough ex-
cited by speaking, and with sensation as of a feather in the throat; aggravation in the
evening or at night; expectoration yellow, thick, and fetid; in children with en-
larged cervical bronchial glands this remedy acts admirably.
Drosera.-Violent cough with convulsive movements of the abdominal and
thoracic muscles, perspiration on waking; sensation as of a feather in the throat, and
stitches in the larynx ; aggravation at night after lying down; the mucus may be gray,
yellow, or green; coughing and vomiting.
Hyoscyamus.-Convulsive cough, worse at night, aggravated by eating, drink-
ing, or vocal exercise; stinging or titillating sensation in the larynx; expectoration
at first of white mucus or of greenish color. For incessant cough, day or night, giving
no rest, this remedy is invaluable.
Hepar sulph.-Deep, dry cough, with oppression and soreness in the chest;
bubbling rales in the chest; cough worse toward morning in scrofulous subjects; ex-
pectoration tenacious or loose; substernal stitches; wheezing respiration.
Iodine.-Dry cough in children, with swelling of cervical and bronchial glands,
night sweats and emaciation, suffocative feeling and dyspnea; palpitation of heart;
expectoration mucous or bloody.
Ipecacuanha.-Cough attended with nausea and vomiting, pale bluish com-
plexion, asthmatic breathing, soreness of the chest, sensation as if dust had been in-
haled.
Kali bichrom.-Cough hoarse and whistling, attended with nausea and tick-
ling in the throat. Expectoration of thick mucus or of muco-purulent matter, tongh,
stringy, sometimes fetid.
Lachesis.-Violent spasmodic cough, worse at night, with choking sensation,
relieved by sitting up; pains in the throat, eyes, and head; expectoration scanty; or
184
A SYSTEM OF MEDICINE.
suddenly profuse, frothy, tenacious mucus is expectorated, which causes relief. This
remedy is often indispensable in violent nocturnal coughs of bronchitic subjects.
Lycopodium.-Dry teasing cough of feeble emaciated boys, also in (bronchi-
ectasis) coughs with dilatation of the air-tubes. Expectoration scanty, yellowish or
grayish-yellow or dirty; respiration difficult during the cough.
Mercurius sol.-Dry cough, worse in the evening and at night, with sensation
as if the chest would burst, tickling in the chest, perspiration without relief; thick,
white-coated tongue, alternate chills and heat; expectoration of thick yellow mucus.
Pulsatilla.-Dry cough, violent in a warm room and at night; expectoration
thick, yellow, and free.
Phosphorus.-The bronchitis of emaciated, thin, and delicate subjects; cough
sharp and dry, with tightness across the chest, and pain when coughing. Expectora-
tion worse in the morning; it is viscid or bloody, worse from speaking, laughing, or
going into the cold air.
Sanguinaria.-Dry cough, with tickling, crawling sensation under the sternum,
and sensation of dryness and constriction of the air-passages; chest sore and painful,
burning and stitching pains in the chest. Expectoration scanty or profuse.
Stannum.-Cough attended with pressure deep in the chest, and with feeling of
constriction; sore pain throughout the chest; dyspuca, wheezing, and rattling in the
chest; aggravation from using the voice; hoarse cough, dry, or with green or yellow
expectoration with a sweet taste, especially indicated when attended with great weak-
ness.
Rumex crispus.-Great sensitiveness of the mucous membrane to atmospheric
changes; suffocative feeling extending to the epigastrium; hoarse, barking cough at
night and in the morning; cough incessant and dry, with tickling in the larynx and
trachea; cough worse, and aggravated by going into the air.
Spongia.—Croupy, dry cough, with mucous rales; hard, dry, racking cough,
with dyspnoea and slight expectoration, continuing day and night.
Tartar emetic.-Cough with vomiting; loud rales with sensation of suffoca-
tion; expectoration difficult, with sound as though it would be easily expectorated;
paroxysms of rattling cough in the night; vomiting.
Consult also Cina, Conium, Nux vomica, Veratrum viride.
Prophylaxis.-Daily bathing the chest, or, better still, the upper
half of the body, with cold salt water, thus exposing it to a tempera-
ture several degrees less than likely to be encountered during the day,
affords most hope of diminishing the tendency to bronchitis. The
patient should endeavor to avoid living in rooms overheated by a
furnace. In this country a temperature of 68° is about as low as can
be endured.
Locally. Inhalations of steam are useful, and in violent spasmodic
coughs ether or chloroform may be inhaled for a few moments if the
spasms are urgent; glycerinated water may be used in the steam
atomizer for producing expectoration. Every case of bronchitis occur-
ring in those with any tendency to pulmonary trouble should be care-
fully treated from the first. It is advisable to diminish the cough and
expectoration speedily, so as to prevent any further effects which may
result from extension of the inflammation which has attacked the
mucous surface. Patients should be particularly warned against mak-
ing themselves too tender and effeminate, and should be directed to
restrain the cough to the greatest extent possible.
Capillary Bronchitis.-Aconite may be required at the onset, but it is not
as powerful a remedy as Belladonna. The marked effect of this remedy in diminish-
DISEASES OF THE RESPIRATORY ORGANS.
185
ing capillary congestion brings it specially into service in a disease characterized by
capillary inflammation involving so great an extent of surface. It will be found to
diminish the dyspnea and also to mitigate the dry cough in a marked degree. The
special indications for it have been already given.
Tartar emetic is indispensable; to the symptoms already given, we may add
those common to incipient poisoning by Carbonic acid; the rattling cough ends in vom-
iting, or continues loose, with simply a disposition to vomit. Indeed it will be found
that no inconsiderable proportion of cases of capillary bronchitis will yield to these
two remedies.
Ipecacuanha may be required. This remedy has also bubbling rales in the
chest, great dyspnoea, with a suffocative cough, and vomiting of mucus occurs more
usually than under Tartar emetic.
Mercurius sol. may be useful. It is specially useful where there is a pre-
dominance of gastro-intestinal symptoms, coated tongue, diarrhoea, alternations of
chill and heat, and profuse perspiration.
Hepar sulph., Spongia, Opium, and Ver. viride may also be con-
sulted.
In the conduct of a case of capillary bronchitis, one of the most
essential considerations is to maintain a uniform temperature; every
experienced physician knows how frequently relapses have resulted
from neglect of this one precaution after the case had been carried
almost to a successful termination. It is not advisable to urge perspi-
ration. As the case grows serious perspiration will be profuse, and
yet there will be no relief from the occurrence of this symptom, but
rather still greater prostration. The temperature should, therefore, be
uniform, from 72° to 75°. When there is a disposition to violent spas-
modic cough, inhalations of steam may be employed. It is only
necessary to start the steam atomizer and direct the current of spray
toward the child.
Chronic Bronchitis.-Definition: A low form of inflammation
of the bronchial mucous membrane, usually attacking adults, and
characterized by its tendency to recur.
Etiology. It may occur primarily or secondarily: primarily,
when it is the result of the acute affection, or after exposure to cold
or of irritating dust, vapors, or any irritating substances; secondarily,
during the course of acute rheumatism, cardiac or renal disease, syph-
ilis, emphysema, bronchiectasis, and during phthisis, the exanthems,
and chronic alcoholism. By far the larger proportion of cases occur
in old people. It rarely occurs in children except as a sequela of
measles and whooping-cough.
Symptoms. The symptoms of chronic bronchitis resemble those
of the acute form. The most prominent of those are cough and ex-
pectoration. We have the same substernal pain, oppression of the
chest and dyspnoea, but these latter are not usually so well marked in
the chronic form. In order to make the subject clear, it will be neces-
sary to treat all the different forms as they are commonly encountered.
These are winter cough, dry cough, bronchial irritation, bronchorrhoea,
and fetid bronchitis.
186
A SYSTEM OF MEDICINE.
The most common variety is Winter Cough. The patient does not
suffer much during the summer months, but in the fall the cough sets
in either in slight paroxysms or increases to violent paroxysms, which
sometimes are very distressing. These cases are generally worse at
night; after a time the attacks become permanent, continuing even
through the warm months, and characterized by frequent remissions,
and sometimes intermissions. The expectoration in some cases is
moderate in quantity, and is mucous or muco-purulent; in other
cases it may become very abundant, and is mainly, muco-purulent or
purulent, or it may be a sticky, tenacious, grayish mucus.
It is gen-
erally of a yellowish-white color, sometimes greenish-yellow, some-
times dark-green, and if the larger tubes are affected, it is aerated and
floats in water; when the smaller tubes are mainly involved, it is more
solid and sinks in water. There is little fever; when fever exists, it is
noticed towards evening, and there may be some disposition to night-
sweats. The digestive organs are involved to some extent, producing
moderate anorexia, furred tongue, and constipation; but the distin-
guishing feature of bronchitis, even if there is involved quite an ex-
tensive amount of bronchial mucous surface, is that the disposition to
febrile movement is not marked. Usually, there is but little loss of
tissue. Emaciation is rarely marked, but there may be some wasting
of flesh and loss of strength, dependent upon the permanence and
extent of the chronic bronchitis. The amount of dyspnoea in uncom-
plicated bronchitis is slight; if we have asthma or emphysema com-
plicating, there may, of course, be severe loss of breath.
Dry Catarrh.-This form, which is described by Laennec as catarrhe
sec, is observed quite frequently. As its name implies, there is little
secretion, and that which is formed originates in the smaller tubes.
The irritability of the mucous membrane, and its dryness, result
in the production of violent, long-continued, distressing paroxysms
of coughing, attended with swelling of the veins; the face becomes
turgid and red; the paroxysm results in very little expectoration;
at times, masses of tough, viscid, semi-transparent, grayish mucus,
like boiled starch, are expectorated; the paroxysms are attended
with soreness of the chest and dyspnoea, and not infrequently with a
feeling of constriction; they often resemble whooping-cough and ter-
minate in vomiting. There is no febrile movement at all, and the
general health is unaffected.
Bronchorrhoea, also, occurs in paroxysms. The expectoration may
be moderate, even scanty, or copious, and sero-mucous, viscid, stringy,
transparent, sometimes like the white of an egg, and again thin,
clear and watery; it may be slightly aerated on the surface. The
quantity of the discharge may be enormous, in some cases from
two to three pounds within a few hours; the expectoration is some-
times blood-tinged, a result of the severe strain produced by the vio-
DISEASES OF THE RESPIRATORY ORGANS.
187
lence of the coughing fit, and the patient, after an attack, is much ex-
hausted and bathed in copious perspiration. The attacks are more
liable to come during the night or in the early morning. Bronchor-
rhoea particularly attacks those who are troubled with some cardiac
affection. Between the paroxysms the patient is not much troubled
with dyspnoea, unless there is valyular disease or emphysema.
The strength is not affected to the degree one would suppose from
the amount of expectoration. The patient will expectorate four or
five pounds in the twenty-four hours, and yet be able to attend to
business. If the disease is long-continued, there may be some ema-
ciation and general weakness, but unless the cardiac complication
tends to a fatal termination, the patient may suffer for a long time
with this form.
Laennec quotes an instance of an old man of seventy years, who had
expectorated for twelve years four pounds daily of a muco-serous
fluid, without appreciable injury to his health. I had, under my own
charge for years, a gentleman suffering from this form of catarrh, who
would expectorate a sufficient amount to fill a good-sized cuspidor in
the course of 24 hours, and yet take the care of a large business with
apparent ease. In this case the patient died suddenly from pul-
monary edema as the result of a mitral lesion.
Fetid Bronchitis has a violent and sudden cough, more severe in
the morning. The expectoration is opaque, thin, semi-transparent,
and in large quantity, or scanty; it is often difficult to expectorate.
It may be grayish-yellow, greenish or brownish; it is but slightly
aerated, and usually sinks in water. It has a marked fetor, resem-
bling that from gangrene of the lungs. The fetid odor is usually sup-
posed to result from decomposition of purulent matter in the sacculated
dilations of the bronchi, but there are cases in which the expectoration
is fetid, and yet post-mortem examinations show no dilatation. In
this variety we have marked constitutional symptoms, febrile move-
ment, hot dry skin, increased frequency of the pulse, and prostration.
The causes of the putrid secretion of bronchitis are not yet clear.
Traube noted the presence of putrescent yellowish-white exudative
flecks of bronchial mucus in the sputa, which consisted of fine granu-
lated detritus and margaric acid.
Professor Leyden and Dr. Jaffreys demonstrated this detritus to be
composed of cryptogamic, thread-like sporules with incessant ciliary
motion. These Hartwack regarded as of the same family of fungi as
those observed in the mouth, and termed leptothrix pulmonalis (Mey-
hoffer, Chronic Diseases, p. 268); Meyhoffer states that his microscopie
investigation of putrid sputa led to the recognition of the same spor-
ules as those above described; globules of fat, granules of dark pig-
ment, crystals of margaric acid, and elastic fibres.
This variety is most common in persons of a strumous diathesis,
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exhausted and broken-down constitutions, and particularly in those
addicted to chronic alcoholism. The fetid breath of the patient is an
important symptom; it is often more significant than the sputa. The
physical signs are similar to those in acute bronchitis. Inspiration
and expiration are labored, and there is diminished expansion of the
chest; it may be enlarged uniformly, especially in dry catarrh, which
has resulted in the production of emphysema.
Palpation.—Vocal fremitus is not markedly altered; in severe
cases it may be exaggerated; when there is complete obstruction of
the tubes, it is diminished or absent. Rhonchal fremitus is present in
different parts of the chest, changing its position or degree.
Percussion. The sound is usually normal, unless a coincident.
emphysema has given rise to exaggeration. Dulness may result from
the accumulation of secretion in the bronchi in cases of bronchorrhoea.
Auscultation.-There is diminished vesicular murmur over the
chest. Expiration is prolonged in old cases; the quality of the respi-
ratory sound is harsh, loud and coarse; after free expectoration, the
breathing-sounds are more plainly heard. We have the dry rales,
sibilant and sonorous, or the large and small bubbling rales, circum-
scribed or extensively diffused. In those cases characterized by
abundant secretion, the rales may be temporarily absent, or they may
be quite persistent. Their number and persistency may be changed by
coughing or deep inspiration. The different forms of chronic bron-
chitis described will give rise to much variety in the character of these
rales. Vocal resonance may be normal, diminished, or slightly ex-
aggerated.
Diagnosis.—The diagnosis of chronic bronchitis from phthisis is
sometimes a question of much difficulty. Ordinarily it may be done
with ease, but when there is emaciation, abundant purulent expectora-
tion, with febrile movement, hæmoptysis, and other symptoms of
phthisis, we have to make not only a very careful physical examina-
tion, but take the rational signs into consideration. The fact that the
dilated bronchi yield the loud bronchial or even broncho-cavernous
respiration adds to the difficulty.
If, however, we bear in mind that chronic bronchitis has but little
febrile movement, that during its course the emaciation, even when
present, does not proceed with the same rapidity, that it is not de-
pendent upon heredity, that the intermissions are very marked, and
that it is fairly amenable to treatment, we can establish very soon, if
not at once, a positive diagnosis. From pleuritis and pneumonia it is
readily diagnosticated by the absence of the characteristic physical
signs of these affections.
Chronic bronchitis is amenable to treatment, but its complete cure,
placing the patient beyond the danger of a relapse, is difficult. The
severer cases are dangerous from their tendency to produce emphy-
DISEASES OF THE RESPIRATORY ORGANS.
189
sema, dilatation of the bronchial tubes, and, in some instances, fatal
collapse. While we do not believe that the disease may extend into
the air-vesicles and become the immediate cause of phthisis, there is
no doubt that in those who are phthisically inclined, bronchitis may
be the exciting cause of the deposit of tubercle. In those who have not
a phthisical tendency, a winter-cough may exist for twenty or thirty
years, and not lead to consumption. Complete cures may be effected in
most of the varieties, provided the patient is constantly under obser-
vation, and follows the direction both as to internal medication and
climatic changes. We cannot subscribe to the view that chronic
bronchitis is an incurable disease.
Pathology. Chronic bronchitis gives rises to passive congestion.
of the bronchial mucous membrane. It is obvious that the different
varieties above described are attended with varying conditions of the
mucous surface. In some cases there is marked inflammatory action,
involving also the sub-mucous structures. Accompanying the hy-
peræmia, there is excessive cell-promotion. If we examine the mucous.
surface, it will be found discolored, sometimes of a bluish hue, at
others of a pale red or gray color; the hyperæmia may be diffuse or
circumscribed, streaked or punctiform, and there may also be ecchy-
mosis present; varicose vessels are seen. The sub-mucous tissue be-
comes infiltrated. When bronchiectasis exists, the larger tubes are
dilated diffusely or in a saccular manner; the muscular coats of the
tubes are hypertrophied, and their elasticity is gone; calculous depos-
its exist in the cartilages. Superficial lesions of the epithelium occur,
and follicular ulceration at times exists. The secretion varies with each
form. Emphysematous lobules are present to a greater or less extent.
In some cases there are slight alterations in the consistence of the
bronchial mucous membrane, particularly when a purulent secretion
has existed for a time.
Treatment.-Most of the remedies mentioned in the treatment of
acute bronchitis may be required in some cases of the chronic form.
In addition, we must consult:
Ammonium carb.-For bronchorrhea with copious secretion which it is diffi-
cult to expectorate; the cough occurs in the morning and evening, and is sometimes
incessant, aggravated from eating, talking in the open air, and on lying down; expec-
toration generally scanty, consisting of mucus mixed with blood-corpuscles.
Arsenicum.-For the symptoms already given; it is specially serviceable in
fetid bronchitis; one of the worst cases of this form, in which the expectoration was so
fetid as to make it almost impossible to remain in the room, yielded in the course of
three days to Arsenicum 6th. In all forms of chronic bronchitis of old people, it is
useful in mitigating the asthmatic symptoms and relieving the irritative symptoms.
Calcarea carb.-For the chronic bronchitis of children we have in this
remedy almost a specific. It is particularly indicated when there is thick, yellowish
expectoration, sometimes fetid; cough dry and spasmodic.
Causticum.-Hard, dry cough, aggravated at night and by the warmth of the
bed, relieved by cold drinks; sputa greasy-tasting; expectoration of tough mucus.
Drosera.-Violent spasms of coughing, ending in vomiting; resembling whoop-
ing-cough; worse on lying down.
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A SYSTEM OF MEDICINE.
Chelidonium is useful in dry, spasmodic cough.
Kali carb.-Dry, spasmodic cough; worse at three in the morning, attended
with nausea and vomiting. The expectoration is of grayish mucus.
Kreasotum in bronchitis of children during dentition; the expectoration is
thick, whitish or yellow.
Silicea.—Obstinate congh, aggravated by cold drinks, relieved by inhaling moist
warm air; expectoration transparent or opaque, tough and tenacious. Meyhoffer says
it is hardly possible to overcome radically the catarrhe pituiteux of Laennec (bron-
chorrhoea without Silicea.
Sulphur in chronic bronchitis characterized by cough, attended with heaviness
of the head and dim vision; expectoration of large quantities of tenacious mucus, or
scanty yellowish white sputa; in putrid bronchitis its action is salutary. It is indi-
cated for those affected with rheumatic or gonty diathesis, and who present character-
istics of great sensitiveness of the skin to atmospheric changes.
Consult, also, Stannum, Phosphoric acid, Sepia, Senega, Pulsatilla,
Phosphorus, Opium, Manganum, Nux vomica, Lycopodium, Iodine,
Ignatia, Cocculus, Carbo veg., Cannabis sativa, Lobelia, Spongia.
Inhalations of warm steam afford relief in dry bronchitis; in fetid
bronchitis, weak solutions of permanganate of potassium or of carbolic.
acid may be inhaled from the steam atomizer with advantage; in
bronchorrhoea we may use hydrastis and pure water, ten drops of the
mother tincture to the ounce. In violent paroxysms of coughing, it
is far better to inhale a few drops of chloroform than to resort to cough-
syrups, if the indicated remedy does not relieve at once. As a prophy-
lactic, the patient should be directed to take cold salt sponge-baths every
morning, and wear sufficient warm clothing and flannel next to the
skin. Especially should the patients be warned not to remain indoors
too much; they should avoid cold bleak winds as much as possible,
but in all moderate weather they should be out of doors a great deal.
Different forms of bronchitis require different climates. Bronchorrhoea
patients do best in dry warm climates, as in Colorado, Dakota, North-
ern Georgia, New Mexico and Old Mexico; while, for the dry bronchi-
tis, Florida, and especially Southern California, with its moist, soft,
and relaxing atmosphere, is better.
Croupous Bronchitis.-Definition: An inflammation of the
bronchi, characterized by fibrinous exudation, giving rise to the ex-
pectoration of casts of the bronchi.
Synonyms.-Bronchial croup, fibrinous bronchitis, pseudo-mem-
branous bronchitis, bronchial polyps.
Etiology. The disease is very rare. Liebert reports but 17 cases
of acute fibrinous bronchitis, after careful collection of all the cases
known. The chronic form of the disease is more frequent. It occurs
more frequently in men than in women, and oftener in youth, and in
localities where there is a prevalence of bronchitis; only two cases.
have been observed in infancy. Its connection with syphilis, rachitis
and scrofulosis has not been fully established. The debility of con-
DISEASES OF THE RESPIRATORY ORGANS.
191
stitution which results in these dyscrasic conditions may, however,
play some part.
Croupous bronchitis is characterized by a spasmodic paroxysmal
cough, generally painful and dry, or attended with expectoration, as
in ordinary bronchitis. The severity of the symptoms depends upon
the size of the casts and the ease with which they are expectorated.
The acute form has a moderate amount of fever, with oppression in the
chest, anorexia, and such symptoms as generally attend a bronchial
attack. Some cases begin with a severe rigor, high fever, great dysp-
nœa, and violent long-continued paroxysms of cough, attended with
asphyxia when the large tubes are implicated; after a severe paroxysm,
the fibrinous casts are expectorated, or portions of the fibrinous mate-
rial mixed with mucus.
In the chronic form we have the history of catarrhal bronchitis
which lasts for a considerable time; we then have the occurrence of a
paroxysm ending in the expectoration of fragments of fibrin or casts;
in some instances the effort of sneezing may cause their exfoliation. In
some cases we have symptoms of phthisis preceding the exfoliation of
the casts, with slight attacks of hæmoptysis. The symptoms recur
from time to time, between which there are periods of complete health;
some of the paroxysms are exceedingly severe, and with these there
may be considerable catarrhal expectoration; at times there is blood
in the interior of the casts, or streaks of blood on their exterior. The
casts vary in size and thickness as well as in form; those from the
large tubes are solid, those from the smaller tubes are cylindrical.
The attack may give rise to an excessive acute bronchitis, with abun-
dant muco-purulent expectoration, or may result in the setting-up of
a pneumonitis attended with the usual history of this affection. The
surface of the casts is generally smooth, but there may be irregular
swellings in places. This bulging is regarded by some writers as the
result of bronchiectasis. Biermer states that they are due to the exu-
date finding obstacles to its extrusion in some places, and thus it is
not so uniformly thrown out.
Some casts exhibit small spiral portions; they are generally firm
and elastic; the finer casts are softer and more gelatinous. In color
they are milky-white or yellowish-white.
Microscopically, they consist of a structureless amorphous material
with pus-cells, abundant granular matter, and some oil-globules ;
blood-globules are not found within the substance of the casts, but, as
we have heretofore seen, may be upon its surface or within them; they
have been regarded as due to remnants of blood poured out into the
tubes, which is coagulated and decolorized, but their position shows
them to be due to a true exudation from the mucous surface.
Physical Signs.-When there is well-marked exudation, the signs
of obstruction may be present in the chest; circumscribed dulness,
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A SYSTEM OF MEDICINE.
weakened or absent respiratory murmur. After coughing and removal
of the obstruction, the signs just mentioned may disappear. Sibilant
and sonorous rales, and at times bubbling rales, are heard, in various
portions of the chest; if there is loose membrane, it may give rise to
rubbing or flapping sounds.
Diagnosis.—Croupous bronchitis may be mistaken for acute bron-
chitis, pneumonia, or pleurisy, but the nature of the paroxysm, together
with the characteristic expectoration, will aid in making a correct
diagnosis. We differentiate it from pneumonia and pleurisy by ex-
clusion of the signs belonging to these affections.
Prognosis.-The acute form is very fatal, inducing a mortality of
about 50 per cent. The chronic form is not so dangerous as regards
life, but as foreshadowing phthisis or leading to pneumonia, it is serious.
The duration of the disease varies from three to ten days for the fatal
cases, or from ten to fourteen in those attended with recovery. The
paroxysms of the chronic form continue from ten to twelve days, but
their recurrence is marked by longer or shorter intervals, rarely termi-
nating in complete recovery.
Treatment.-Very little clinical experience with the disease under
homoeopathic treatment has been recorded; obviously it would require
much the same treatment as croupous laryngitis. For plastic exuda-
tion into the bronchi we have in Phosphorus the best remedy. Under
the use of this drug, absorption of the membrane is effected. Bella-
donna would be indicated for the attending capillary congestion in the
early stages of the acute form. We refer to Aconite both as tending
to prevent exudation and as one of the leading remedies to control the
violent spasmodic cough.
Inhalations of steam are serviceable, and should be continued per-
sistently. Weak solutions of Hamamelis, Hydrastis, and Iodine may
also be employed. The continued application of warmth to the chest.
promotes the loosening of the casts. Dry heat is preferable in the
form of flannels frequently heated, or of a hot-water rubber-bag con-
taining a moderate amount of water, so that the weight of it be not
oppressive.
BRONCHIAL ASTHMA.
Definition. A disease attended by paroxysms of urgent dysp-
nœa, recurring at intervals, with or without cough, and characterized
by periods of health between the attacks.
Synonyms. Spasmodic asthma; (French) Asthme; (German)
Bronchial-asthma.
Ætiology.-Predisposing Causes.-Undoubtedly dyscrasia is at the
foundation of all causes. It is hereditary in the proportion of about
40 per cent. No particular dyscrasia can be assumed to directly pre-
dispose; it may be connected with the scrofulous or rheumatic dia-
thesis, likewise with the phthisical or syphilitic. It occurs at all
DISEASES OF THE RESPIRATORY ORGANS.
193
periods of life. Loomis relates a case where a paroxysm of asthma
occurred in an infant six weeks old, born of an asthmatic mother.
The majority of cases have been noted as occurring from the period of
one to ten years, while few occur between ten and twenty. The cases
occurring in old age are usually a chronic bronchitis without the typi-
cal asthmatic attacks; asthma may, however, occur in the old as a
result of this form of bronchitis. Men are affected in the proportion
of two to one to women.
The exciting causes are divided into direct and indirect. Of the
direct, the irritation produced by some morbific substances attacking
directly the bronchial mucous membrane furnishes the largest con-
tingent. These excitants are irritating inhalations, as Ipecacuanha
powder, smoking, the dust of the streets, the emanations from new-
mown hay, those of atmospheric and climatic conditions particularly,
and the exhalations from certain animals. It is difficult to assign the
part played by conditions of the atmosphere. Some patients are better
in dry air, some in moist. The favorable effect of the removal from
the country to the city, even to localities where the air is close and
heavy with smoke, is well known. Again, damp dwellings, and those
upon marshy ground, particularly dispose to the disease.
Indirectly, we include those cases in which the asthmatic paroxysms
result from indigestion, which cases are termed "peptic asthma," from
irritants in the rectum, from uterine excitation, application of cold to
the surface, wet feet, chilling the spine, mental emotions, and those
which result from brain disease.
Among diseases which induce asthma, bronchitis heads the list, giv-
ing rise to 80 per cent. of cases. The hyperemic bronchial mucous
membrane is exceedingly irritable and sensitive to the slightest appli-
cation of an exciting cause in those who are susceptible. Cardiac
trouble may also give rise to it.
We do not include under bronchial asthma those cases of dyspnoea
which arise during the course of cardiac disease; but there are, un-
doubtedly, instances in which genuine idiopathic asthma results dur-
ing the course of cardiac lesions. Emphysema may also indirectly
act as a cause.
The form which we term hay asthma, produced by emanations from
new-mown hay or other vegetable substances, is well-marked asthma,
usually either preceded or accompanied by rhinitis and bronchitis. Not
all those who are afflicted with hay-asthma have the violent parox-
ysms, but there is more or less dyspnoea associated with it, and in
the end the paroxysms are likely to occur as in all asthmatics.
In measles and whooping-cough, children are liable to be subject
to violent attacks of asthma; the proportion of such cases is not in-
considerable.
Varieties of Asthma.—The forms of bronchial asthma may be
. VOL. I.-13
194
A SYSTEM OF MEDICINE.
included under two heads: idiopathic or primary, and symptomatic
or secondary.
The idiopathic form is the form most typical, occurring independent
of any other affection. These cases are undoubtedly purely neurotic
in their origin, although back of them lies the constitutional dyscrasia
predisposing. Indeed, it is now claimed that even hay-asthma, which
has, it is well known, a direct exciting cause, should be grouped under
the neuroses.
Idiopathic asthma has many points of resemblance to epilepsy, as
the attacks come on at regular intervals, or at least the periodicity is
quite well marked. The attack seems to act first as a kind of climax,
and after its occurrence the patient, who before was dreading an attack,
is relieved from his fear for a considerable period, and again exposes
himself with seeming impunity to influences which, it seems, would
induce a cold and a paroxysm. Salter states that he has known two
or three instances in which one kind of attack took the place of
another.
Symptomatic or secondary asthma occurs in three forms, the peptic,
bronchitic, and cardiac. Peptic asthma depends upon the ingestion
of certain kinds of food into the blood, the latter producing a peculiar
effect upon the bronchi when circulating through them. It is not
properly an attack of indigestion, otherwise the trouble would be mani-
fest soon after partaking of food, while these attacks occur at a period
varying from one to three hours after eating. The ingestion of wine,
which is quickly absorbed, will induce an attack sooner.
Bronchitic asthma furnishes about 80 per cent. of all the cases. Every
person subject to chronic bronchitis is in danger of the occurrence of
spasmodic asthma. This we may understand from the investigations.
of Störck, who has demonstrated by laryngoscopic examination that
the mucous surface of the trachea and large bronchi is hyperemic
during the prevalence of the attack. We may fairly conclude from
the phenomena which obtain in the smaller tubes, that this same
extreme degree of hyperæmia extends even to the bronchioles. The
mucous surface then may be said to be constantly in the condition of
susceptibility to spasm. The intractability of the disease is thus seen.
If the bronchitis remains during the periods of exemption from the
spasms, the patient is constantly ready for another attack.
The third variety, which is the least common, cardiac asthma, de-
pends entirely upon the pulmonary congestion which is the result of
the blocking up of the right heart. Cardiac dyspnoea, unattended
with any spasm of the bronchioles, is almost always a constant accom-
paniment of the cardiac lesions, but the form referred to is attended
with wheezing, prolonged expiration, and all the symptoms belonging
to a genuine bronchial spasm.
Symptoms.-There is one class of cases in which there are no
DISEASES OF THE RESPIRATORY ORGANS.
195
prodromic symptoms, the attack coming on at once. Others are char-
acterized by well-marked premonitory symptoms which are mainly
referable to the nervous system, the patients experiencing either men-
tal exhilaration or depression. There are some cases in which there is
a dull and lethargic condition, with irresistible desire to sleep. Again,
in some there is well-marked aura; some patients are attacked with
profuse diuresis, passing large quantities of clear, pale urine, like spring
water, corresponding to a similar condition observed in hysterical pa-
tients.
The initial symptoms are marked in some cases, and not present in
others, or at least the patient sleeps through the initial symptoms and
is not conscious of them.
They consist of slight indications of the characteristic dyspnoea of
asthma. The patient feels constriction across the chest; there is dry
cough, some wheezing and disposition to remain quiet; there is disten-
sion of the epigastrium from flatulence, the development of gases in the
stomach being so large that an actual increase of size of the abdomen
and chest takes place. These initial symptoms may continue for some
days before the occurrence of the attack, but the patient is aware of an
increased sense of constriction, and there is a greater amount of wheez-
ing; in other cases we find no occurrence of initial symptoms at all,
the attack coming on with the utmost suddenness. The time of the
occurrence of the spasm is usually in the early morning from two to
four; cases may occur at other times, but it is not common.
One pa-
tient who had the severest attack I have ever encountered began at
about nine or ten in the evening. Usually, the patient retires feeling
as well as usual, but after sleeping from one to three hours he awakens
with the attack.
In peptic asthma, the attacks follow soon after a meal, usually after
dinner or supper. The period when the patient is most free from
suffering is the forenoon. Even those who almost constantly experi-
ence dyspnoea may be free from it at this period. When the paroxysm
is established, the position of the patient is significant; he sits up in
bed or in a chair, with his elbows resting upon the knees, or with his
head fixed and his shoulders raised. Some take a kneeling position.
either on the floor or bed or against a chair. The patient is pale, or, if
the attack is bad, cyanotic. Perspiration is very free, particularly after
the accessory muscles of respiration are brought into full effort, and
the paroxysm is violent. During the intensity of the paroxysm the
shoulders are thrown high up, the head back, with each inspiration
the mouth is opened wide, and every muscle which can be brought
into play is called into action. The clothing is loosened, particularly
about the neck; he sits either by an open window or in the middle of
the room, desiring no one about him, for even the presence of by-
standers increases the feeling of suffocation. The extremities are cold,
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A SYSTEM OF MEDICINE.
the veins of the face are turgid; the eyes staring, and the pulse small
and quick; the asthmatic seems to be almost on the verge of suffoca-
tion, when there is some coughing and expectoration, and the attack
subsides, often quite quickly.
In some cases the degree of suffocation is so great as to produce car-
bonic-acid poisoning, and the paroxysm terminates, for under such
conditions the bronchial spasm must at once cease. In a large propor-
tion of cases the attack terminates by the expectoration of a clear mass
of mucus in small round globules; in others there is expectoration or
profuse watery mucus. The patient often has the idea that it is only
necessary to expectorate to terminate the paroxysm; the fact is that
there is no expectoration until the hyperæmia has existed for some
considerable time. It is not the presence of the expectoration which.
causes the spasm, but the expectoration is one of its results.
In some cases no secretion exists throughout the whole attack. The
thoracic sounds are dry, and the spasm terminates without a particle
of expectoration.
The sputum consists either of masses of clear or of grayish-white
mucus resembling masses of arrow-root or tapioca; it is rarely frothy
or purulent. During violent attacks we may have some hæmoptysis;
in many instances a very small amount of blood is expectorated in
streaks or small patches, and in other cases there is profuse hæmor-
rhage. The hæmorrhage is undoubtedly induced by rupture of the
capillaries of the bronchi which, as we have already seen, are in a
state of intense hyperæmia. The operation is similar to the produc-
tion of bleeding at the nose.
The respirations are diminished in frequency, falling in some in-
stances as low as nine to the minute. One would at first suppose
from watching the patient during an attack that he would experience
an increase in the number of respirations; but while the inspiration
is short, the expiration is prolonged, sometimes to a very marked ex-
tent, and this accounts for the small number of respirations per minute.
After the subsidence of the attack the patient is left weak and pros-
trated according to the severity of the attack. Those who are accus-
tomed to the paroxysms, after a sleep of two or three hours, will fre-
quently go to their business as usual, only feeling languid for the day.
There is then a period of health, but sooner or later another attack
recurs. These are periodical, many patients being able to fix the
period of their attacks with absolute accuracy. Some are taken every
night, others do not experience a recurrence oftener than once a month
or a year.
The most marked illustration of this is shown in hay-
asthma, which has an interval of a year, and yet returns with singular
periodicity almost upon the very day, and, in some instances, at the
very hour. Cases have their peculiarities, and there is a probability
that the attacks will grow lighter from year to year. This is partly
**
DISEASES OF THE RESPIRATORY ORGANS.
197
due to the fact that the patient becomes habituated to the paroxysms,
and is not so nervous at the period of their recurrence. The milder
attacks occur more frequently than do those of great severity.
Physical Signs.-Inspection.-During the paroxysm, inspection of
the chest shows that the respiratory efforts are labored, but that there is
after all little actual motion; the muscles strive to raise the ribs, but they
do not yield, and notwithstanding the violence of the respiratory effort,
the movements are not increased in frequency; inspiration is short and
jerky; the intercostal spaces are markedly depressed; the expiration is
very long, and ends suddenly and violently with the expiration of the
last portion of air, followed at once by a renewed inspiratory effort.
The vocal fremitus and resonance are normal.
Percussion shows the resonance exaggerated. This is due to the
distension of the chest and to the emphysematous condition of the
lobules.
Auscultation.-The respiratory murmur is loud, at times exag-
gerated, at others suppressed, dependent upon the degree of bronchial
stenosis. In the severe cases the bronchial tubes are completely oc-
cluded, and we have an actual want of respiration. There is no res-
piratory murmur, not because the loud sounds overtop, but because it
is actually non-existent. The rales are usually dry and sibilant, or
sonorous and of a high-pitched or hoarse sound. They are diffused
either over the whole chest or situated at circumscribed spaces. They
are significant in that they are inclined to change their site, although in
very many cases the extent of the bronchial implication yields no char-
acteristic symptom save the loud musical rales of high pitch. These
imitate many sounds, being screeching, chirping, whistling, cooing,
snoring, etc.; they are usually louder upon expiration, but may be
heard with both sounds. We explain the varying site of these sounds
by the fact that there are constantly going on changes in the seat of
the bronchial spasm, moving from place to place, and from side to
side. There are cases in which during attacks of asthma bubbling
rales are present. These occur generally in those subjects in which
there is a bronchitis attended with considerable expectoration ante-
dating the paroxysm.
Pathology. The pathology of asthma is exceedingly interesting;
it illustrates the diverse views which may be held by different authori-
ties, and the inability of establishing therapeutics upon a pathological
basis. In the early history of asthma the existence of the affection in
an idiopathic form was denied by Rostan, Louis, and others, who en-
deavored to establish it merely as a symptom of other affections. But
the labors of Biermer, who resurrected the abandoned theory of a
spasm of the bronchi and bronchioles, resulted in securing for this
view the respect of many. Wintrich, however, combated this view,
maintaining that the spasm was produced by a tonic spasm of the dia-
hragm, or by a spasm of the diaphragm and respiratory muscles
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A SYSTEM OF MEDICINE.
combined. This view was supported by Bamberger and Leyden.
(Ziemssen, 531, vol. iv.)
In discussing this question, it is important to first note the labors of
Storck, who ascertained by microscopic examination the presence of
hyperæmia of the trachea and bronchi, and partially of the right
bronchus. From his observations he was led to believe that the
stenosis was due to a swelling in the bronchioles of the mucous mem-
brane, this occluding their calibre. The fallacy of this view seems ap-
parent when we consider that it is possible, and indeed, this often occurs,
for the bronchial spasm to subside almost instantly, and its physical
signs to suddenly become lost; we can hardly imagine that there is
such a prompt subsidence of the hyperæmia and swelling of the mu-
cous membrane as to accomplish this result.
The ingenious theory which has been advanced by Leyden that the
bronchial spasm results from the irritation produced by octohedral
crystals has not as yet been determined with accuracy. They are sup-
posed to be composed of a substance analogous to mucine. Leyden
maintained that these crystals irritate the terminations of the vagus
nerve in the bronchial mucous membrane, giving rise to a reflex
spasm, and hence the phenomena of the attacks. The weight of evi-
dence seems to be in favor of the view that the true nature of the asth-
matic paroxysm is the constricted state of the bronchial tubes.
The view of Wintrich that the cause of the paroxysm is dependent
upon a tonic spasm of the diaphragm, or upon a spasm of the dia-
phragm and respiratory muscles occurring simultaneously, is supported
by other pathologists, especially Bamberger and Lehmann. The physi-
cal signs of the paroxysm induced Wintrich to hold that it was not
possible to result simply from constriction of the smooth muscular
fibres of the bronchioles. He believed that the enlargement of the
lungs which occurs during an attack could not be the result of the
constriction caused by the action of the bronchial muscles.
argued that if spasmodic asthma were caused by the contraction of
the muscles, the effect would be felt both during inspiration and expi-
ration, which is not the case, as we know that the inspiratory air-
pressure is not diminished.
He
It seems reasonable, on the contrary, according to Bamberger, that
the obstruction to respiration is shown by the fact that it is forced and
prolonged, together with the absence of the sibilant rales showing con-
striction in the medium-sized and smallest bronchi. He cites the in-
vestigations of Bert, who succeeded in producing contractions of the
bronchi by galvanization of the lungs and also of the vagus. He,
morcover, affirms that the bronchial muscles are the antagonists of the
inspiratory muscles, and act for respiratory purposes in unison with
the elasticity of the lungs, and also advanced the view that the bron-
chial muscles may act as a sphincter muscle whose action is more
DISEASES OF THE RESPIRATORY ORGANS.
199
easily overcome in inspiration than in expiration. The position taken
by Biermer has the support of Trousseau, Salter, and Romberg, and is
confirmed by the experiments of Bert.
Diagnosis. It is not easy to mistake asthma, as the nature of the
paroxysm is ordinarily sufficiently diagnostic; since we have limited
asthma to its essential forms, it is not easily confounded with any other.
diseases. There are varieties of bronchitis, or heart trouble, and of
emphysema which may simulate it. Asthma can be distinguished by
the sudden onset of the paroxysm, and by the absence of the charac-
teristic purulent expectoration of bronchitis which very rarely occurs
in asthma. The dyspnoea is sometimes quite severe, remains for some
length of time, and is not relieved instantaneously.
Cardiac dyspnoea resembles it most; both occur in paroxysms, and
they are both intense; each usually occurs at night and in a recum-
bent position; the intervals of the attacks are characterized by normal
respiration. Physical examination enables us to diagnosticate the
cardiac disease with certainty. Cardiac dyspnoea has no physical signs
of a constriction of the bronchial tubes; there is no wheezing, no pro-
longed respiration, no suppression of the respiratory murmur; these
signs are never wholly absent in asthma.
In emphysema the dyspnoea is the result of chronic lesion of the
lung, and it is never entirely wanting, while in asthma the difficult
breathing may be entirely relieved between the paroxysms.
The physical signs serve also to establish the differential diagnosis.
from acute capillary bronchitis. It may be distinguished by the
marked febrile movement of the former, and the slower onset and re-
lief of the dyspnoea.
From the spasmodic affection of the larynx it is distinguished by
the absence of the characteristic stridor and hoarseness of laryngeal
troubles.
Prognosis.-Asthma, uncomplicated, rarely terminates fatally. In-
deed, the popular idea that asthmatic patients are protected from other
forms of lung trouble and are long-lived is generally well founded.
It is to be noted that there are some exceptions to this rule, for a
certain class of asthmatics are, later, affected with phthisis pulmonalis,
one attack predisposing to another; length or shortness of the inter-
vals at which the attacks occur affects very much the prognosis. Those
patients who have but infrequent attacks, and who are well during the
interval, enjoy, as a rule, excellent health and are not in danger.
When the attacks are frequent and severe, the danger of the production
of cardiac trouble or emphysema is greater. When asthma exists
with an inveterate bronchitis, the case, although not hopeless, is likely
to be exceedingly intractable. Age greatly influences the prognosis.
Young children will recover completely while an old asthmatic will
be relieved. The dyscrasia of the patient has more to do in influenc-
200
A SYSTEM OF MEDICINE.
ing the prognosis than any other one factor. If asthma occurs in the
phthisical, the syphilitic, or the scrofulous, the disposition of the dis-
ease to be affected through complication is very great. Whenever the
attacks can be attributed to some well-known cause, as, for instance,
irritant inhalations, the prognosis, as regards complete recovery, is good.
Treatment.-Aconite.-For violent attacks occurring in the robust, and in the
early evening, with heat, restlessness and profuse perspiration; great nausea; the pa-
tient is unable to speak at all; full bounding pulse, and expectoration blood-streaked,
with cardiac palpitation. The worst case of asthma which I ever encountered, and
which had existed for several years, yielded quite promptly to Aconite 3d. The pa-
tient was a strong, vigorous adult, and the attack characterized by intense violence.
Apis. Suppression of urine; aggravation by warmth; feeling of constriction of
the chest; cannot bear throat covered.
Aralia.-Dry, wheezing respiration; aggravation on lying down; very marked
acrid mucus from nose and throat; sore feeling in the sternum and in the lungs. In
the paroxysms accompanying hay-asthma it has been found of benefit.
Argentum nitricum.-Frightful paroxysm, aggravated by drinking or
talking, and with suicidal mania.
Arsenicum.-Paroxysms at night, obliging him to sit up at once and to bend
forward; restlessness and increased aggravation from motion, by warmth, and during
stormy weather; dry, hard paroxysms of cough, followed by expectoration of frothy
mucus, streaked with blood. Burning pain in the chest, profuse perspiration, and great
prostration. In the dry asthma and in the asthma of old people it is especially
valuable.
Belladonna.-When the attacks occur in the afternoon and evening, in hot
weather, after sleeping, by motion, and from use of stimulants; constricted feeling of
the larynx, great oppression of the chest, paroxysms of dry cough.
Bromium.-Great dyspnoea, with sense of constriction; dry hacking cough;
useful for the asthma of sailors which occurs as soon as they go on shore.
Baptisia.—When the lungs feel tight, sharp pains in the chest, paroxysms end
with unusually copious expectoration.
Cuprum.-Attacks occur suddenly and cease suddenly; aggravated by coughing,
laughing and drinking, and at the period of the menses. It is indicated for children
or hysterical women when the attacks are induced by fright or mental emotions; dry
suffocative cough, worse at night, with anxious feeling at the heart.
Ferrum. For full-blooded children who flush easily and who are subject to epis-
taxis, dyspnoea, palpitation of the heart, paroxysms of spasmodic cough, with expec-
toration of tenacious mucus, and with attacks, occurring after midnight, which are
relieved by moving about, talking, and uncovering the chest.
Grindelia robusta. For attacks of nervous asthma, when the paroxsyms are
severe, dyspnoea great, expectoration at first scanty, afterwards becoming looser, with
considerable mucus thrown off.
Ipecacuanha.-Expiration labored and slow, dyspnoea violent, and suffo-
cative feeling great, cyanosis, constriction of the throat and chest; goes to the open
window; cough constant and severe, sounds loose but no expectoration; paroxysm
terminating in vomiting, which affords relief; extremities cold.
Lachesis.-Asthma attended with great constriction of the chest and stuffed
feeling, palpitation of the heart; cyanosis, wheezing; slow difficult expiration; im-
patient of any pressure on throat or chest; cannot lie on left side; aggravation from
sleeping, from eating, from motion, and from touching the chest.
Lobelia.—Asthma aggravated from exertion, by indigestion attended with weak-
ness in the stomach, pressure on the epigastrium, attack preceded by prickling all over,
extending even to the fingers and toes; dyspnoea urgent and sudden, cannot bear the
slightest exposure to cold.
Moschus.-Suffocative attacks as if due to vapors of sulphur; paroxysms caused
by desire to cough, and gradually growing worse, causing the patient to despair of
relief; aggravated by the least exposure to cold; soreness in the axillary regions; most
suitable to hysterical people.
DISEASES OF THE RESPIRATORY ORGANS.
201
Nux vomica. For the asthma of dyspeptics who have overindulged in coffee
or stimulants. Dyspnoea relieved by eructations, also by changing position; worse
from cold air or exercise; cough dry and short; expectoration slight, and effected
with difficulty; great irritability.
Opium.-Marked congestion of the chest; deep, stertorous, rattling breathing;
suffocative attacks during sleep; loose cough and bluish redness of the face; aggra-
vation from eating, or drinking wine, and smoking, and relieved from cold air and
bending forward.
Pulsatilla.-Attacks come on in the evening after eating, and are attended with
dizziness, and aggravated by heat, by walking, by exercising. Cough dry at night,
loose in the daytime, attended with nausea and vomiting. If there is abnormal men-
struation or suppression of eruptions, Pulsatilla is very serviceable.
Sanguinaria.-Deep inspirations, increasing the tightness of the chest; cough
dry, and relieved by sitting up in bed and eructating. Cyanosis; accelerated respira-
tion; is of service in hay-asthma.
Sulphur.-Invaluable in chronic asthma attended with oppression of the chest,
without pain; bubbling rales in the chest ; suffocative attacks at night; pressure and
burning in the chest, attended with expectoration of whitish or yellowish mucus;
attacks recurring every eight days, and recurring in the morning.
Stannum. -Violent cough, followed by copious expectoration of yellow-streaked
whitish mucus; aggravation in the evening and at night, and by the least exercise.
Tartar emetic.-Predominance of bubbling rales in the chest, great oppres-
sion and suffocation, particularly in the evening or morning in bed, great dyspnea,
inability to lie down, suitable for children and old people.
Veratrum alb.-In cases attended with extreme prostration, cyanosis, cold
extremities, and perspiration; weak, feeble pulse.
Pulmo vulpis, on the authority of Von Grauvogle, for the asthma of old
people, with profuse expectoration.
Consult Alumina, Ambra, Asclepias, Bryonia, Phosphorus, Ammo-
nium, Aurum, Benzoic acid, Cocculus, Dulcamara, Sabadilla and
Spongia.
General Treatment.-When a paroxysm of asthma supervenes,
the patient should be placed under the most favorable hygienic con-
ditions. Free ventilation must be secured, and the patient placed in
a room with but a single attendant, in a chair, so arranged that he
finds something to lean upon. Some asthmatics stand, but ordinarily
the position in a chair, leaning forward, is the best.
If there is any irritating vapor or dust which has provoked the attack,
it should obviously be at once removed.
If the attack is due to an overloaded stomach, vomiting should be
at once provoked.
If constipation has been marked for some days, an enema should
be administered at once.
Some patients are so weak that they prefer to sit in bed, in which
case a chair may be placed in front of them on which they can lean the
head. Attacks usually yield readily to the indicated remedy. Once
in a while we meet with a case characterized by great stubbornness and
intractability. Such a case I once treated in the early years of my
practice. The patient was a lady of about forty, whose asthma resisted
the most careful selection of remedies, both high and low. A cure was
effected by sending her to Mackinaw, Michigan, for the summer; after
202
A SYSTEM OF MEDICINE.
this, the paroxysms, which had before occurred with great frequency,
did not recur in twenty years.
Inhalations.-Those who are not accustomed to tobacco often
derive great service from its use during a paroxysm. I am not inclined
to subscribe to the view that asthmatics are relieved by habitual
smoking; in the long run the continued use of tobacco is unquestion-
ably injurious. Its medicinal use may be carried to an extent suffi-
cient to produce a moderate sense of faintness and nausea, but not to
induce vomiting.
Stramonium enjoys a high reputation for the immediate relief of a paroxysm.
Stramonium cigarettes are prepared, or the leaves are smoked in a pipe. Arsenical
cigarettes have also been advised.
Chloroform.-The worst spasm can usually be subdued by the use of this
agent. Its effects, however, soon disappear, and the paroxysm returns even worse than
before. It is not wise to resort to its use except as a dernier ressort. It is given in
doses of 5 to 10 drops in a little milk or by inhalation.
Nitre paper.-Most asthmatics well know the use of this remedy. The papers
are prepared by putting hard blotting paper, cut into pieces six or eight inches square,
into a strong solution of saltpetre. The druggists usually keep them, so that it is not
necessary to keep them on hand unless one lives at some distance. One of the pieces
may be lighted, and the fumes inhaled. Stramonium and nitre form the basis of most
of the preparations which are sold for the relief of asthma. Some patients are relieved
by the ingestion of a cup of strong coffee, very hot; stimulants, when given hot, half
spirits and boiling water, furnish relief. Nitrite of amyl, a few drops by inhalation,
affords partial relief, but it is only temporary.
Climatic Change.-It is well known to asthmatics that there are
certain kinds of air which they cannot breathe, and others in which
they are entirely exempt from attacks. An asthmatic cannot sleep in
an east room, while he will enjoy a good night's rest in the west room
in the same house. In our country Colorado affords the best climate-
cure, and the summer-resorts of northern Michigan usually afford
marked and, often, permanent relief to the victims of hay-fever.
D. DISEASES OF THE PARENCHYMA OF THE LUNGS.
PNEUMONIA.
BY A. K. CRAWFORD, M.D.
Synonyms.-Inflammation of the lungs, Peripneumonia, Peri-
pneumony, Pneumonitis, Pulmonitis, Peripneumonia vera; from
the Gr. пvεʊμоvía; Fr., Pneumonie; Ger., Lungenentzuendung; It.,
Pnemonitide; Sp., Pneumonitis.
Definition.—Inflammation of the pulmonary parenchyma, charac-
terized by high fever, with a variable degree of pain in some part of
the chest, hurried and oppressed breathing, cough, with viscid and
rusty-colored expectoration, the crepitant rhonchus at first, followed
by bronchial respiration and bronchophony, and a greater or less ex-
DISEASES OF THE RESPIRATORY ORGANS.
203
tent of dulness on percussion. Its onset is sudden, its course definite,
and its inflammatory products are removed by absorption. It is sub-
ject to marked modifications through the existence of constitutional or
specific diseases.
Anatomical Characters.-From the standpoint of acute pneu-
monic inflammation the parenchyma of the lungs refers to the air-
cells, vesicles, or alveoli, and does not include either the terminal
bronchial branches or the connective tissue of the organ. The bronchial
mucous membrane, lined with cylindrical and ciliated epithelium and
mucous follicles, is continuous through the subdivisions of the bronchial
tree to the termination of the bronchioles. The air-vesicles are made
up of a delicate membrane lined with squamous or tessellated epithe-
lium, and totally devoid of mucous follicles, and it is demonstrable
that the bronchial vessels do not reach the air-sacs, but are confined in
their distribution to the bronchial tubes and areolar tissue. It is seen
also that the vessels which ramify the air-sacs come entirely from the
pulmonary artery, and, consequently, this portion of the lung-tissue
must derive its nourishment from the pulmonary vessels, so that, by
reason of the difference in anatomical structure, as well as in function
and blood supply, an acute pneumonitis is confined, as a rule, to the
tissue of the air-vesicles. The rapidity with which the air-cells are
filled with exudative material is circumstantially in favor of its being
the work of the pulmonary, and not of vessels of so small calibre as
the bronchial. To claim that the cellular tissue is the seat of inflamma-
tion, in conjunction with the air-sacs, is still less tenable, for it is found
that the group of air-cells at the termination of each bronchiole, form-
ing a lobulette, has no cellular tissue in its composition. Even the
groups of lobulettes which go to form a lobule possess no connective
tissue, or at most only an occasional trace of it. Between the lobules
it does exist; but there it is separated from the pulmonary circulation,
and by the pathological law that inflammation of a structure does not
usually extend to another structure, the cellular tissue is not likely to
be implicated in an inflammation of the air-cells. Although usually
considered a mucous inflammation, pneumonia is not strictly so, be-
cause of the difference in the anatomy of the tissue involved, and the
consequent important differences in the products of the inflammation.
as compared with those of the bronchial, and other, mucous mem-
branes.
The amount of lung texture found diseased in the post-mortem ex-
aminations of pneumonic subjects has been so variable that numerous
terms have been applied to correspond with these observations. The
more ordinarily accepted divisions are lobar and lobular, although
Andral added, with some reason, that of vesicular. The latter name
is given to pneumonia which attacks individual air-vesicles. This
marks the cut surface of the lung with minute red spots, often not
204
A SYSTEM OF MEDICINE.
larger than a pin's head. Later in the disease, when the blood-tint is
lost, the spots look not unlike tubercular deposits, but they are essen-
tially different in their nature. It is considered quite probable that
this is the mode of development of lobular pneumonia. The term
"lobular" applies to the confinement of the inflammatory process to
a greater or less number of individual lobules. It is the form which
is most common in children, as well as a sequence of major operations
or accidents. It will be considered separately later on. By lobar
pneumonia is meant that type which involves a considerable section.
or the whole of a lobe. It may extend until the whole lung is in-
vaded or even cross to the opposite side, and subject some portion of
that lung to the inflammation. This is the variety of pneumonia
most frequently met with, and which furnishes the truest type of pul-
monary inflammation.
The coincident inflammation of the pleura over the involved por-
tions of the lung is so common that the terms pleuro-pneumonia or
peripneumonia, designating the combination of the two affections, and
pneumonia, have often been used synonymously. But as the pleuritic
inflammation is usually so slight as to have but little or no modifying
influence on the course of the inflamed lung, the compound term does
not deserve such prominence. In these cases the pleura presents
small red patches, and on its surface is seen a thin albuminous de-
posit, but only when the pneumonia is of long continuation does this
exudation tend to become organized. If the pleurisy is sufficiently
pronounced to go on to the development of a considerable amount of
liquid effusion, and thereby exert a baneful influence on the existing
pneumonia, the double term is certainly applicable. Laennec con-
sidered this rarely occurring condition, and no other, true pleuro-
pneumonia.
ACUTE LOBAR PNEUMONIA-CROUPOUS PNEUMONIA.
Pathology. The term croupous was first given to this form of
pneumonitis by certain German authors, and it is now in general.
acceptance. They considered the inflammation of the air-cells to be
precisely the same in its nature as that which invades the larynx in
croup, because of the appearance of the coagulable fibrinous exuda-
tion which filled the vesicles.
Three stages mark the progress of the disease, viz.: First, engorge-
ment; second, red hepatization; and, third, gray hepatization. Any
other states which may result from the inflammation, such as abscess
or gangrene, must be considered exceptions to the rule.
The stage of engorgement is recognized by a darker color than normal
of the lung surface, varying in degree according to the amount of
extra blood the tissue contains, and according to the age of the pa-
tient. The color ranges from the blood-tint seen in the lungs of chil-
DISEASES OF THE RESPIRATORY ORGANS.
205
dren to the dingy, almost black, hue, produced by an excess of pig-
ment, seen in the lungs of the aged. A certain pale opaque condition
of the pleura causes somewhat of a violet color. The impression con-
veyed to the touch is that of a doughy consistence, and pressure elicits
only a slight amount of crepitation. It retains the impression of the
fingers like a surface which is oedematous. When cut, the lung tissue
emits a frothy, bloody serum. The frothy appearance is due to the
admixture of air-bubbles with the lighter or darker sanguinolent
fluid. A section of the lung in this stage, if thrown into water, has
sufficient air in it to keep it from sinking, and if lightly squeezed and
washed, it can be restored to almost its natural condition. The greater
the quantity of fluid, and the less the proportion of air found in the
tissue, the more intense has been the inflammation. Andral was the
first to point out the friability of the lung texture in this stage of the
disease. The engorgement of the tissue renders it more resistant, and
at the same time diminishes its cohesive force, so that the fingers rup-
ture it much more readily than they do the normal lung.
The stage of red hepatization, so called from its resemblance to the
substance of the liver, is marked by a lighter color, a lessened quantity
of fluid, a greater degree of solidity, and an increased friability, as
compared with the characters of the first stage. To the touch it is
both solid and elastic, and yields no sense of crepitation. Slight pres-
sure causes a very little bloody fluid to exude from the cut surface
without a trace of air-bubbles. Firm pressure not only discovers its
greater friability, but reduces it to a red, pulpy mass. The bronchi
with their vessels, as well as the tissue between the lobules, by escap-
ing the inflammatory process, remain lighter colored, and give to a
section of the lung a streaked and specked appearance. By closer ex-
amination the cut surface is seen to be studded with small ovoid bodies,
which give it a granular aspect. These particles are composed of the
exuded albuminous matter coagulated into firm plugs, which com-
pletely fill and are adherent to the air-vesicles. An overflow of the
exudation causes the granules to project into the terminal bronchi,
which has led to the belief that the latter structures had taken part in .
the inflammation. Laennec looked on the presence of these granula-
tions as a necessary part of the stage of hepatization, but they are
found to exist in variable degrees in different cases, or even to be
entirely absent. When they are not present, the lung presents a more
uniform and darker appearance, to which the term splenization has
been applied. Under the microscope the exudation material is seen
to be composed of a granular form of albuminoid matter, with red
and white blood-corpuscles, and an abundance of new cell-formations.
on the air-vesicles. The presence of fatty globules is no doubt due
to the fatty metamorphosis which takes place prior to absorption
of those products. The lung in this stage sometimes enlarges suffi-
206
A SYSTEM OF MEDICINE.
ciently to take the imprint of the ribs on its surface. It does not col-
lapse on opening the thorax, and is found to have increased to over
ten times its normal weight.
The stage of gray hepatization retains many of the characters of its
predecessor, red hepatization. The chief change is in the color, pass-
ing by gradations from the red to a drab stone-tint, by reason of the
infiltration of pus-cells throughout the solidified mass. When in the
process of changing, portions which yet remain more or less red, dis-
persed among the gray, give the tissue the appearance of granite. It
is still solid, granular, and, lacking air, it sinks when thrown into
water. When cut, the tissue may not give forth any purulent matter
until it is pressed between the fingers. Later in the process of sup-
puration the whole lung becomes very soft, assumes a sulphur tint,
and a puncture made into its substance will be immediately replaced
by a well of pus. The vesicular texture disintegrates, and little re-
mains beyond a network of bronchial tubes and vessels and the lobu-
lar septa.
Clinical History. The chill which ushers in the attack lasts va-
riably from half an hour to several hours. In its severity it is com-
parable to the chills of ague or pyæmia, but the latter repeat them-
selves, the former occurs but once. The temperature is found to have.
risen during the continuance of the rigor. The heat increases rapidly,
and about the second day reaches its maximum point. Only bad cases
indicate higher than 105° F. The fever continues to range high up to
the fifth day, at the end of which time, or early on the sixth day, it
begins to decline, and soon falls rapidly. The thermometer shows cer-
tain variations during the twenty-four hours. Its lowest marking is.
in the early morning. During the forenoon it begins to rise again, and
continues going up until the afternoon. The comparatively sudden
termination of the fever, or crisis, does not occur until the process set
up by the inflammation is complete; then it is accompanied by a pro-
fuse sweat, an inordinate flow of urine, or a diarrhoea.
The duration of the different stages may be generalized as follows:
The stage of engorgement, only a few hours; the stage of red hepati-
zation takes twenty-four to forty-eight hours for the exudative process,
and two to four days for solidification to continue before absorption
begins; the stage of gray hepatization is usually terminated in a few
days by death. The first stage may not progress to the development.
of inflammatory products, but simply end by resolution. It more
usually goes on to hepatization, however, and then, instead of ending
in purulent infiltration, it gives way to the reparative process of reso-
lution or absorption. This stage of resolution seldom takes less than
three or four days to remove the solidified exudation, and more fre-
quently occupies twice that time. Many cases do not entirely recover
for some weeks. Sometimes, thus, the whole course of the malady
DISEASES OF THE RESPIRATORY ORGANS.
207
may be compassed within the space of six or eight days, or it may
continue with evening exacerbations for two or three weeks, the symp-
toms remaining with this prolongation of time being confined to the
rather rapid pulse and some dyspnoea, with, may-be, a little of the
cough.
If the disease does not progress favorably, the addition of threaten-
ing symptoms usually takes place about the third or fourth day. The
temperature rises, the pulse becomes smaller and more frequent, and
the difficulty in breathing is very much increased. The patient re-
quires to be propped up, and at the same time works laboriously in
performing the act of respiration. The sputum is deeper tinted with
blood, and becomes so viscid that inverting the vessel containing it
does not displace it.
All authors do not agree on the question of which side is the more
frequently attacked, but the general testimony is in favor of the right
lung being the one most often involved, and of the base more fre-
quently than the apex. Of the comparative frequency of inflamma-
tion of the apices, Grisolle says, that it occurs in the right two and a
half times oftener than in the left.
From the time of Hippocrates it has been known and noted that the
disease has a decided tendency to ameliorate on certain days. These
critical days are commonly the seventh, eleventh, fourteenth, and
twentieth, and but few cases turn toward recovery on days other than
these.
Unless the utmost care is taken, relapses are very apt to take place.
They must be looked upon with apprehension, for much vitality has
already been expended in the first attack, and consequently the
renewal of the fever is more than likely to be adynamic in form, and
the increased sanguinolent secretion is much less readily coughed up,
and the dangers are thereby increased. If the case tends to a fatal
issue, there will be marked failure of the patient's strength, combined
with increased dyspnoea from inability to expectorate all the sputa.
The little that is expectorated is changed in hue and character. It may
assume any opaque, dirty, greenish, drab, or yellowish tint, with blood
and purulent matter mixed through it, and, sometimes, it emits a fetid
odor. It was Andral who first noticed a dark-colored, sticky fluid, not
unlike liquorice-water, expectorated by patients having pneumonia
shortly before their death. Simultaneous with any of these threaten-
ing changes, the pulse will be thready and frequent, the face pale,
cold, and clammy with perspiration, the lips bluish, the respiration
shallow and gasping, and it will be noted that nature kindly blunts
and veils the senses so that the patient is unaware of the distressing
terminal struggle with death.
Causation. The conditions which predispose to an attack of
pneumonia may be set down to its previous occurrence in the indi-
208
A SYSTEM OF MEDICINE.
of these can be considered as
Chomel tells of a patient who
vidual, or to tuberculosis; but neither
common to the majority of cases seen.
had pneumonia ten times. Dezoteux followed one through seven
attacks who had had the disease eight times previously. And Rush
gives the history of a German who had passed through twenty-eight
attacks.
By all means the most frequent and most easily traceable of the ex-
citing causes of pneumonia is exposure to rigorous weather. It is not
merely the severity of the weather itself which does the mischief, for indi-
viduals habitually exposed can withstand the greatest variations of the
thermometer without apparent effect, but those who are either unused
to out-door life, or who, from drunkenness, debauchery, overwork,
mental or physical, or anything which lowers the vitality and staying
powers, will quite readily contract the inflammation when subjected
to a chilling atmosphere, especially if after overexertion or overheat-
ing. The individuals most prone to be attacked are those who are
most actively engaged in life's struggle, and consequently the majority
of the cases occur between the years of 20 and 40; and it follows that
men are more frequently the sufferers than women. The presence of
bronchitis does not necessarily favor an attack of pneumonia, nor
vice versa, for the affections, although so contiguous, are not related the
one to the other. Nor does the condition of emphysema tend to favor
the occurrence of pneumonia. It will, at times, be found to attack and
run the ordinary acute course in a tuberculous subject, possibly con-
fining itself to a portion of non-infiltrated tissue, and terminate with-
out affecting the progress of the phthisis. And it will, too, complicate
cases of typhus fever, as well as of rubeola, in which case it is termed.
"secondary pneumonia." The inhalation of irritating fumes, of toxic
gases, the bite of the rattlesnake, or other forms of blood-poisoning, as
well as pulmonary apoplexy, embolism, or wounds about or within.
the thorax, may give rise to acute pneumonia.
The influence of season is quite marked in the production of this
inflammation, the late winter and early spring months being the most.
fertile in the year. Statistics from hospital practice in Edinburgh
show that about twice as many cases occur during the first six months
of the year as compared with the last six, while the records of both
Paris and Philadelphia hospitals give the proportion of three cases.
between January to June to one case between July and December.
That pneumonia is often epidemic seems to be beyond dispute, and
that in certain localities it is endemic is equally true. In the careful
study of seventy-nine consecutive cases by Chomel, fifty-six had no
assignable cause, the remainder being traceable to the ordinary physical
conditions producing it. Because of the obscurity of its source in so
many cases, and because of the intensity of its fever, it has oftentimes
been relegated to the list of contagious fevers. Its prevalence in the
DISEASES OF THE RESPIRATORY ORGANS.
209
environs of Mount Vesuvius furnishes a good example of the endemic
type, being due there to abundant noxious exhalations.
Symptoms and Signs.-The first indications that acute pneu-
monia is setting in are well-pronounced chills or severe rigors, either of
which soon give way to febrile reaction of considerable intensity. The
patient complains of pain in the chest, not always of a dull character,
even when the pleura escapes being implicated. But this pain differs.
from the pleuritic in that it is not diffused nor shifting, but generally
deep and localized about the region of the nipple. The cough, which
begins early, has a peculiar metallic ring, which is of itself an almost
pathognomonic sign of the disease. It is accompanied at first by a
light, frothy, or glairy sort of sputum, which soon changes to a viscid
quality; then follows the characteristic rust-colored expectoration.
This rust-colored sputum is the result of the thorough admixture of
the mucous secretion with some exuded blood and air-globules,
and occurs in no state excepting the inflammatory involvement of
the air-cells of the lungs. Sometimes the expectoration assumes a
deep-colored appearance, resembling in some measure prune-juice,
from the greater addition of dark blood, or it may become more or
less purulent in character, either of which conditions portends evil.
Or it may be that throughout the whole course of the pneumonia there.
is an entire absence of expectoration, when there is no doubt that the
inflammation exists, and often without developing any more serious
symptoms than if it were present.
The fever ranges high in this affection, higher than in any other
form of pulmonary inflammation. The thermometer indicates usually
about 104° F., and is therefore an all-important aid in the diagnosis.
The pulse is rapid and full, running from 100 to 120 beats per minute.
The respirations are also increased, in fact, more so proportionately
than the pulse. They will number from 40 to 80 to the minute, and,
taken in connection with the number of pulsations in the same time,
completely annul the normal pulse-respiratory ratio pointed out by
Walshe.
The physical signs attendant upon the first stage, or that of engorge-
ment, are: Restrained movement of the affected side, observable both
by inspection and palpation. The hand discovers no alteration from
the normal in the transmission of vocal fremitus. Percussion elicits
slight dulness over the involved portion of lung-tissue, and early in the
engorgement the ear detects diminished respiration in the same locality,
and augmented respiratory sounds in the remaining portions of the
lung. Following this, we have the development of the crepitant rale,
the only marked, definite, or certain auscultatory sign in the stage
of pneumonic engorgement. This crepitant rale was wont to be
considered a rhonchus or dry rale, but it is now believed to result
from the expansion of the air-sacs when they are covered with a viscid
VOL. I.-14
210
A SYSTEM OF MEDICINE.
secretion, and it is consequently classed as a moist rale of the finest
quality.
Stokes has drawn the attention of the profession to a physical sign
in the initial period of an attack of pneumonia, which, if evidencing a
condition common to the larger part of the cases having this disease,
should be counted one of the regular and reliable signs. He argues
that, as all membranes undergoing inflammation have always a stage
of dryness prior to either engorgement or exudation, therefore the air-
cells of the lungs, in assuming this state, would present, if seen, intense
arterial injection and a bright vermilion color. And the auscultatory
sign corresponding with this condition, he says, is that of a "harsh,
loud, puerile, respiratory murmur." In the cases in which he had
the opportunity to examine them thus early, Waters was able to fore-
tell by this sign the portion of the lung which eventually became the
seat of the exudation, and thereby substantiated the clinical value of
Stokes's sign.
In the stage of red hepatization there is a modification of the pain,
if it existed in the first stage, but the cough and expectoration con-
tinue. The cough is less painful to the patient than it was, and the
sputum is less hard to raise, is more abundant than before, and grad-
ually loses its rusty appearance. The pulse is now small and more.
frequent, owing to the obstructed pulmonary circulation, and the
breathing continues to be rapid. In this stage, too, the invasion of
more lung tissue is apt to take place. If the primary attack involved
only one lobe of the lung, it is likely to progress to another lobe; or
if a whole lung is first inflamed, a lobe of the opposite side may be
invaded. This increase of extent of the inflammation seldom ex-
hibits the signs pertaining to the initial attack. There is little likeli-
hood of a chill marking its commencement, or of the crepitant rale
being heard in the newly inflamed part.
In the second stage the physical signs are more definite and numer-
ous than in the first. Inspection shows the increased respiratory
movement of the well side, as well as the restricted action of the
affected side. The vocal fremitus is usually increased, although this
is not invariably so, for in some cases palpation makes out a dimin-
ished thrill. A dull percussion note is found as certainly as there
exists consolidation of the lung tissue, and the solidified portion may
be mapped out by this means. Auscultation furnishes the signs of
loud tubular breathing or bronchial respiration, a total absence of
vesicular murmur, and the transmission of the vocal sounds exagger-
ated to the degree of bronchophony. By means of the solidification
the heart sounds are also heard through the lung with peculiar clear-
The three most marked and significant of the physical signs in
the stage of hepatization are, therefore, " dulness on percussion, bron-
chial breathing, and bronchophony."
ness.
DISEASES OF THE RESPIRATORY ORGANS.
211
The stage of absorption shows gradual and progressive improvement
in the condition of the patient. The fever no longer holds its reign,
but diminishes until it ceases entirely. The cough is much less fre-
quent and troublesome, and the breathing becomes more natural.
With the return of the appetite, the strength of the patient increases
apace. But if, instead of absorption of the exudative material, sup-
puration should set in in this third stage, the pulse will become more
frequent and weak, the expectoration will assume a purulent quality
and become more abundant, and the respirations will be more rapid.
The already exhausted vitality of the patient will be further taxed
and drained, and the chances are that it will end in death by asthenia.
The physical signs of the process of absorption will be found in a
decreasing degree of dulness on percussion, although there is apt to
be some dulness existing for a considerable time. The loud bronchial
breathing heard in the previous stage gives place to a greater or less.
mixture of the bronchial with the vesicular murmur, termed the
broncho-vesicular; and as resorption goes on, there is less and less of
the tubular quality heard, until it is no longer present, and the breath-
ing assumes the normal vesicular. As the bronchial breathing dimin-
ishes, the crepitant and subcrepitant rales reappear, and die out again.
when healthy respiration is reached. These are the râles redux of
pneumonia, indicative of the air-cells resuming their normal function.
The sign of bronchophony, so prominent in the second stage, is no
longer heard in the third stage, having given way to an exaggeration
of vocal resonance, and soon the normal vocal sound only is trans-
mitted.
There are other conditions to be found in pneumonia than those
already enumerated, all of which may not be common to every case,
but they are sufficiently frequent and important to bear careful con-
sideration. The examination of the urine detects an excess of urea,
and very often there is a trace of albumen, but the most significant
change is that of the absence of the chlorides. They remain absent
during the height of the fever, and reappear when resolution begins,
for it is in some way dependent upon the process of exudation that
the chlorides are withheld from the kidneys. The urine is scant in
quantity, high-colored, by reason of the bile acids and the excess of
urates present, and it ranges in weight from 1025 to 1035 by the
urinometer.
Along with the general sense of aching in the back, the loins, and
limbs, complained of by the patient, headache is also added to his
list of pains. The latter is sharp, lancinating, and frontal, and usually
increases in severity up to the fourth day, and then subsides.
The delirium which so often attends the course of pneumonic in-
flammation is usually preceded by a period of sleeplessness, the patient
exhibiting restlessness, vacant staring of the eyes, and some tremor of
212
A SYSTEM OF MEDICINE.
the muscles. It bears no relationship to the delirium of that rare
affection "cerebral inflammation," but is seemingly due to either a
condition of blood-poisoning, or to an altered state of the blood from
the presence of some foreign material held in it. When the brain of
a delirious patient has been examined after death, not only has there
been no sign of congestion or inflammation, but it has presented, at
times, some degree of anæmia. Thus, whether this delirium occurs in
connection with one of the exanthems, with pneumonia, pericarditis,
erysipelas, or alcoholism, it may be ascribed to a combination of these
factors. There is another state wherein delirium frequently occurs, to
which the delirium attending a local inflammation may very justly be
compared, and that is in traumatism. The one by an accident, and
the other by an acute disease, succeeds in arresting the normal func-
tion of a part of the system and interfering with the patient's mode
of life. If to this be added a debilitated state prior to the onset of the
disease, a weakened heart, or some mechanical interference with its
action, and a depraved state of the blood, the resemblance between
the surgical and the medical cases is strong, and it is possible that the
consequent delirium may be identical. It is a grave complication in
pneumonia, and should be obviated, if this can be accomplished, or
checked in its course as soon as possible.
The face usually assumes a circumscribed dark-red flush on one or
both cheeks, corresponding in the choice of sides, usually, to the lung
involved. The flush is more common to cases of inflammation of the
apex than of the base, and so is the delirium more usual when the
upper lobe is attacked. The eyes present a lustrous hue, and with
the increase of respiratory embarrassment the ale nasi work with a
fan-like motion.
Pneumonia may be complicated with malarial symptoms, from the
presence in the system of a former or newly contracted ague, and it is
not rare that typhoid symptoms should also develop in a case. A
little care only is necessary to prevent confounding typhoid pneu-
monia with typhoid fever having pneumonia added as a complication.
The one is, primarily, inflammation of the lungs, with an adynamic
state impeding its progress, just as any fever of local inflammatory
origin may assume a typhoid condition. The other occurs when the
pulmonary affection is secondary to, and superimposed upon, an
otherwise ordinary case of typhoid fever.
When pneumonia occurs in conjunction with cases of acute articu-
lar rheumatism, its attack is usually so insidious that it is very apt to
go undiscovered until the lungs are in full possession of the inflamma-
tion. First, because the patient may complain of no chest pain, and
may have no cough or expectoration; and second, because the slight
degree of dyspnoea that may be evident is likely to be attributed to
cardiac complication with the rheumatism.
DISEASES OF THE RESPIRATORY ORGANS.
213
As the heart is so frequently in sympathy with articular inflamma-
tion, the chest should be subjected to frequent examinations in an
acute rheumatic attack, and at such examinations the lungs should
receive due attention to see that pneumonic consolidation does not
creep in unawares. There is one feature about pneumonia and rheu-
matic fever combined which is encouraging, and that is its well-pro-
nounced tendency toward recovery, for most of the cases get well
whether the pulmonary involvement is discovered early or late. When
there is any concurrent cardiac inflammation with pneumonia, the
pulse does not resume its normal beat as soon as it does otherwise.
Instead of the pulsations steadily lowering through the third stage of
the disease, they keep up an unusual frequency for a longer or shorter
time after convalescence is established.
Diagnosis. The onset, the nature, the course, the symptoms, and
the physical signs, all combine to form so clearly defined a picture of
pulmonary inflammation that its diagnosis is generally made without.
trouble.
The sign of crepitation is found in ædema of the lungs as well as in
pneumonia. The same portion of the lung texture is involved in both,
and in both the air-vessels are subjected to a fluid exudation; hence.
the same morbid sound is emitted. This, with the dyspnoea present,
gives oedema some resemblance to pneumonia. But in the former
there is no fever; the rales, crepitant and coarse, are diffused and two-
sided, and the sputum is frothy, but never bloody. The signs of
hypostatic congestion are very insipid as compared with pneumonia.
The fever is slight, and so is the expectoration; there is no dulness,
but simply a lessened degree of percussion resonance over the bases of
both lungs. The respiratory murmur is feeble, and there are, in addi-
tion, some few moist rales heard. From phthisis it is differentiated by
the rapid development of the symptoms in pneumonia, with previous
good health, in opposition to the impaired health and progressive
course of phthisis. In pneumonia the lower portions of the lung are
usually the seat of disease; in phthisis, the upper. They may co-
exist, and acute phthisis may proclaim itself at the termination of an
apparent acute pneumonia. If there is doubt about the nature of the
affection in such instances, the after behavior, as well as the family
and personal history, will distinguish them. Pulmonary hæmorrhage
is likely to give evidence of its occurrence by some bleeding from the
mouth and nose. It exhibits its greatest degree of dyspnoea at the
commencement, while the respiration in pneumonia increases in em-
barrassment during the first four days. The expectoration in the one
is of pure blood; in the other, of frothy, bloody mucus, and fever is
absent in hæmoptysis.
Other conditions which give evidence of solidification of pulmo-
nary tissue, and consequently have some signs common with pneu-
214
A SYSTEM OF MEDICINE.
monia, are atelectasis, pulmonary collapse, pleuritic effusion, and the
presence of coagulated lymph blocking up the pulmonary vesicles,
to the chapters on which the reader is referred for their special
diagnosis.
Prognosis. The favorable or unfavorable progress of a case of
pneumonia is, as a rule, determined by the state of the pulse, the res-
piration, and the temperature. The greater the frequency of the pulse
and breathing, and the higher the range of the thermometer, the more
violent is the inflammation, and when these are excessive, the first
danger to the life of the patient is from the intensity of the fever, and
the second is from the extent of the exudation, which may destroy life
later on by apnoea.
Pneumonia in infants is a very fatal malady, but in children from
five to fifteen years of age it does not prove to be so. Barthez pub-
lishes a table of 212 cases of pneumonia occurring between the ages of
two and fifteen, with only two deaths.
The death-rate between the ages of fifteen and forty is also small if
the disease runs an uncomplicated course. But if pneumonia is
secondary to some acute dyscrasia, such as measles or typhoid fever,
it is attended with many dangers, and may readily be fatal. After
fifty years of age the mortality increases very much, and by adding
drunkards to the list of the feeble, the deaths mount up to sixty or
seventy per cent. Deaths are more frequent when the inflammation
attacks the upper lobes or roots of the lungs than when the bases are
involved, possibly because of the pressure exerted on the larger ves-
sels and tubes in the former case, thus cutting off the supply of air
and blood from the non-inflamed parts.
Much may be learned from the sputum to aid in determining the
prognosis of pneumonia. After being viscid and rusty, if it becomes.
more free in quantity and less tenacious and bloody, the inference is
that resolution is established and recovery quite promising. But if it
becomes over-profuse and of a thin, serous quality, or of a dark,
brownish-red color, or if it disappear entirely, the prospect is the
reverse of encouraging. The condition of the sputa and their signifi-
cance are much altered and modified if catarrh, bronchitis, or phthisis.
exists with the pneumonia. When the other symptoms are not cor-
respondingly grave, the disappearance of expectoration does not sig-
nify, but if rattling of the secretion is heard with each respiration,
along with absence of sputa, denoting paresis of the vagi, ædema may
set in at any moment, and death will ensue.
Should the urine, previously cloudy, become clear before the fourth
day, while the inflammation is still active, the chances are against the
patient, and so is the appearance of albumen in this stage a bad sign.
If by the sputum or by the exhalations from the breath there is evi-
dence that gangrene has invaded the lung tissue, the condition is full
DISEASES OF THE RESPIRATORY ORGANS.
215
of peril, although several such cases are recorded as surviving the
attack.
LOBULAR PNEUMONIA, CATARRHAL, OR BRONCHO-PNEUMONIA.
This special form of the disease bears the imprint of inflammation
simultaneously in both the bronchial tubes and in the air-cells of the
lungs. The names do not apply to any true croupous pneumonia
where, probably from the intensity of the inflammation, the bronchial
tubes also appear reddened and more or less inflamed, but to a pneu-
monia that follows a catarrhal or inflammatory condition of the
bronchial tubes.
It is therefore a secondary pneumonia, being preceded frequently by
whooping-cough, measles, or capillary bronchitis, and, like the latter
affection, is confined almost entirely to the extremes of life. It is
probably never met with in adult life, unless in connection with pyæ-
mia, the puerperal state,* or subsequent to the severe injuries of surgi-
cal operations and accidents. The terms "circumscribed," "patchy,"
and "lobular " refer to the limitation of the inflammation to isolated
sections of lung tissue scattered throughout the whole.
Viewed pathologically, the inflamed foci do not present the granular
appearance of the consolidated tissue in croupous pneumonia, but a
smooth homogeneous look. The air-cells contain desquamated epithe-
lium and leucocytes, but no exudation. The development of this mal-
ady in an infant may be first noticed by the augmented respiratory
movements, or by the aggravation of the cough every time nursing is
attempted. The rales heard are more of the subcrepitant and coarser
order than those found in the lobar variety of adults. Dulness on per-
cussion is an unreliable sign, therefore does not help to distinguish
lobular pneumonia from bronchitis; neither are the other ordinary
signs of pneumonia to be depended upon.
But if the fever suddenly rises several degrees, with increased em-
barrassment of respiration, lessened cough, probably signs of localized.
dry pleurisy, and the discovery of a few dull and inert spots over
the chest-wall, the inference is strong that the bronchial inflamma-
tion has extended into the air-cells of the lungs. The two diseases,
capillary bronchitis and catarrhal pneumonia, differ much in their
duration, the former running its course much more speedily than the
latter. With the predisposition of children to develop brain-symp-
toms in acute fevers, they prove to be specially liable to delirium in
pneumonia, and they therefore suggest the possibility of the local in-
flammation being meningeal rather than pulmonary. But the ther-
mometer will obviate any liability to confound them, for in pneumonia
the record is high, and is continuously so, while in meningitis it has
* See Jousset's Clinical Medicine, page 393.
216
A SYSTEM OF MEDICINE.
marked remissions. Infantile peritonitis also bears such resemblance.
to pneumonia in its continuous fever, rapid pulse and quick breathing
that they require to be differentiated from each other at times. In
peritoneal trouble the development of abdominal tympanitis will be
sufficient to direct the attention to the locality inflamed.
The catarrhal pneumonia of the aged is insidious in its attack, diffi-
cult of detection, and asthenic in its course. A complication that
sometimes befalls pneumonia in advanced life is the occurrence of hem-
iplegia. It involves the same side of the body as the diseased lung,
but does not signify any grave state, for it is not of central origin, and
disappears with the abatement of the pulmonary inflammation.
Treatment.-The record made by homoeopathy in the treatment
of pneumonia is so exceptionally good that any and all other modes of
practice and schools of medicine may be challenged to compare results,
and with perfect safety in so far as the laurels of homoeopathy are con-
cerned. Leaving out of the question the statement published by Dr.
Hughes Bennett that he lost only a little more than three per cent. of
his cases of pneumonia, because it has been shown that his affirmations
are unreliable in several particulars, the nearest approach to the success
attained by homoeopathy is found in the Vienna test of the "expect-
ant" method of treatment. During the first year of this trial, the
mortality was only about seven and one-half per cent., but subsequent
statistics of series of pneumonic cases treated without medication
increased the average mortality to nearly nineteen per cent.
In the Sainte Marguerite Hospital of Paris, pneumonia was treated
homœopathically by Tessier and allopathically by Valleix and Mar-
rotte, for a consecutive period of three years, with the result of three
per cent. less mortality under homoeopathy. The losses by death from
pneumonia in two hospitals there, conducted homœopathically, were
five and six per cent. respectively, while under old-school treatment
the mortality ranges anywhere from twelve to thirty or thirty-five per
cent.
Not only is the death-rate so greatly diminished by homoeopathic
treatment, but the duration of the disease and the severity of its course
are lessened materially. For instance, in one of the tests just cited,
with the same number of beds and in the same period of time, the
homœopathic service cared for some three hundred cases of pneumonia
over and above the number treated by the allopathic corps. And it
has been definitely noted that under this modern-school system of
treatment, the febrile symptoms gradually decline, instead of termi-
nating abruptly with defervescence as is the natural tendency of the
malady.
There is even a greater difference than this in the persistence of the
physical signs under the expectant treatment, as compared with their
duration under homoeopathy. In the former, although the fever may
DISEASES OF THE RESPIRATORY ORGANS.
217
have subsided about the ninth or eleventh day, the physical signs
continue up to the twenty-fifth or thirtieth day, while in the latter
they are frequently non-discoverable after the eighth day.
Entering now upon the consideration of the remedies in use for the
treatment of pneumonia, the number is found to be limited, and the
specifications concerning each are, in the main, both definite and well
agreed on. In speaking of this, the British Journal of Homœopathy once
put it that
we may say that our knowledge of the treatment of
pneumonia is as perfect as is our diagnosis of the disease."
(6
Aconitum.-There is usually the utmost accord among homeopathic physicians.
as to the time and adaptation of this remedy to a disease; but there is a division in the
ranks about the place Aconite should hold and the value that should be attached to it
in the therapeutics of pneumonia. Kafka says it has never given him any results
when he has used it in croupous pneumonia. Jousset totally ignores the drug; and
Hughes says that if you expect much from Aconite in pneumonia you will be disap-
pointed. On the other hand, Baehr writes that no one who has watched the striking
effects of Aconite will ever doubt its great virtues in this disease. And Carroll Dunham
states that Aconite may be employed in pneumonia and other pure inflammations, and
may do an heroic work. He considers its time of administration to be during the
stage of arterial excitement, prior to that stage which is characterized by local deposit;
if promptly and judiciously used, it may cut short the entire disease. Again S. H.
Hayward says that if aconite is given in the initiatory chill, in the early reactive fever,
or in the stage of simple vascular engorgement, in a case of uncomplicated pneumonia,
the morbid process will almost always be arrested within twenty-four hours. The uni-
versal testimony of physicians on this side of the water accords with the views last ex-
pressed.
The special symptoms calling for Aconite are: Great anguish of mind and body,
restlessness, and disquiet that can not be allayed; high fever, preceded by a chill, with
burning heat and dryness of the skin, full and bounding pulse, and a deep redness of
the face; labored respiration, dull pressure and weight on the chest, or stitches in the
chest during a deep inspiration and during motion; dry, racking cough with some
tenacious, blood-streaked expectoration; headache; intense thirst; scanty and high-
colored urine; the recumbent posture on the back; and the physical signs pertaining
to the first stage of the disease.
Veratrum viride. This remedy supplements aconite, and, like aconite, has
the credit of being able to abort pneumonia when it is given early, and in the tincture
or a low dilution. Its symptoms are: High temperature, very rapid, hard and strong,
or intermitting pulse: flushed face; labored respiration; dry and hacking couglf with
abundant and bloody expectoration; red streak through the centre of the tongue; and
sinking, faint feeling in the pit of the stomach. It lowers the pulse and the tempera-
ture with extraordinary rapidity, and although the respirations may not be so markedly
affected, the dyspnoea is never distressing to the patient, even in bilateral cases of pneu-
monia.
Bryonia was considered by Tessier the remedy for pneumonia. He prescribed
it in every case, and frequently gave no other from the beginning to the end. Jousset
is quite as warm a champion for Bryonia, and as the remedy for the benign form of
pneumonia he claims that it fills all the indications.
The provings of the drug show that it is capable of producing exudations in the lungs
of a thoroughly fibrinous nature, and in this wise it presents us with a better patholog-
ical picture of the disease than does any other remedy. The peculiar adaptability of
Bryonia to the inflammation of serous membranes and the stitch-like character of the
chest pains so often occurring in its pathogenesis, places this remedy at the head of the
list for the treatment of pleuro-pneumonia.
Bæhr recommends its use after the fever has abated, and when red hepatization is
fully established, but this is altogether too long delayed. To accomplish its greatest
good, Bryonia must be given during the process of exudation, for, even according to
this author's own showing, if resolution is too tardy, or if gray hepatization sets in,
Bryonia is of no further use, so that, unless the case tends toward speedy recovery,
this remedy has but an indifferent position among his therapeutics of pneumonia.
Phosphorus.-This remedy is indicated when the patient exhibits something
218
1
A SYSTEM OF MEDICINE.
of a typhoid condition, and the tongue presents a dry appearance with a dark brown
coating on it. It is well adapted also to cases of catarrhal pneumonia. But even in
true croupous pneumonia, when the sharp pleuritic pains of Bryonia are not present,
when the attack has not been caused by exposure to dry cold winds, and when the
patient is of a tall and spare build, Phosphorus is usually even more efficacious than
Bryonia. The peculiar use of these two remedies in the treatment of pneumonia, as
formulated by Tessier, is called by Jousset the "classic treatment" of that disease.
If, after having given Bryonia, a progressive diminution of the frequency of the pulse
is not noted within twenty-four to forty-eight hours, and other symptoms are increasing
in gravity, Phosphorus is prescribed for the night, and the Bryonia continued through
the day.
Probably the finest hospital record ever made in the treatment of pneumonia was
that of Fleischmann, of Vienna, who by the use of Phosphorus alone cured 95 per
cent. of his cases.
Tartar emetic is indicated in the stage of resolution when there is oppression
of the chest, and difficult breathing. The pulmonary inflammation is on the decline,
and the vesicles, as well as the smaller bronchial tubes, seem to be filled with
a viscid secretion, not tinged with blood, which the patient finds the greatest difficulty
in raising. It is, therefore, particularly useful in broncho-pneumonia, the form of the
malady so common in infancy and old age. The dyspnoea is accompanied with wheez-
ing and rattling of mucus in the air-passages. The expectoration may be completely
suppressed, with fits of suffocation and a spasmodic cough, or if bronchial catarrh is
present and the hepatization persists, there may be a considerable amount expectorated,
but only after much effort. It is the remedy for pneumonia supervening on whooping
cough or emphysema, or delirium tremens, and is only the more strongly indicated if
gastric catarrh complicates the case. The attendant symptoms are: a livid or pallid
countenance; a frequent pulse; a lowered temperature; a loose cough, with great
anxiety; and a cool, moist skin.
Sulphur.-When high febrile symptoms persist after the completion of exudation,
and the stage of resolution is delayed, without the development of typhoid symptoms;
when the pneumonic processes seem to be at a stand-still, and there appears to be
danger of purulent infiltration setting in, instead of terminating by resolution, Sulphur
is the remedy called for. The time for its employment is about the fifth or sixth day
when there is a great lack of reactionary force. It quickens into life the reabsorption
process in such cases. The face is frequently puffy in appearance, and there is a great
tendency to sweats. Eidherr recommends its use from the beginning of the exudative
process.
Mercurius is a remedy little used in the treatment of pneumonia, but both
Müller and Bæhr give it a definite place among the therapeutics of pulmonary inflam-
mation. In epidemic broncho-pneumonia, Behr says, it is a leading remedy, as well
as in the catarrhal or lobular form, and Müller thinks it specially well adapted to the
third stage of pneumonia. The symptoms indicating Mercurius are: a continuous but
not intense degree of fever; the skin is at times dry and hot, and again is covered
with profuse perspiration; a dry, rough, irritating cough, worse at night; sometimes
a slight amount of yellowish-green expectoration streaked with blood; dyspnoea un-
changed or slightly increased; violent headache, stupor and light delirium; the
tongue is coated yellow and soon becomes dry; the urine is cloudy and scant. In fact,
the tendency is wholly in the direction of a typhoid condition. In children, when they
have suffered from whooping-cough, bronchitis, or a severe influenza, and signs of pneu-
monic exudation set in, Mercurius proves to be a valuable remedial agent.
Hepar sulph is a companion remedy to the aforegoing, or rather is the one
which best follows it, when to the conditions found under Mercurins the suppurative
process is added. There will be signs of hectic fever, with only limited portions of the
lung infiltrated with pus. It is specially valuable also in pneumonia retarded by a
concurrent bronchitis.
Iodine. Instead of employing either Bryonia or Phosphorus in the first stage of
pneumonia, Kafka prefers this agent. He claims that Iodine cuts the inflammation
short, while other remedies only modify it.
Bromine resembles Iodine in its action, but is preferable if the hepatization
becomes more extensive, and when the Iodine has not fulfilled its mission.
Arsenicum album is never required in an ordinary case of pneumonia, but
when the disease assumes more and more of a grave aspect, its employment may be
demanded. It is indicated when there is extreme prostration, restlessness, pallor of
DISEASES OF THE RESPIRATORY ORGANS.
219
the face, coolness of the surface, periodical exacerbations, considerable dyspnoea, and
an irregular pulse.
Lycopodium.-When the inflammation assumes a low type, or if it has already
reached a chronic condition before it is seen, and the characteristic symptoms of the
remedy are present, then Lycopodium will prove beneficial. It is called for when the
right side is most involved, when there is a fan-like motion of the alæ nasi, circum-
scribed redness of the cheeks, constant cough with abundant mucus, or grayish and
bloody expectoration, and a marked aggravation of the symptoms from 4 to 8 P.M.
Chelidonium.-Teste considers this remedy preferable to Bryonia when the
subject is of a light complexion and placid temperament. He has also commended it
very highly for catarrhal pneumonia or capillary bronchitis in children. Ludlam says
he has used it with the greatest success when these affections could not, readily, be
distinguished at the bed-side. The indications for its use resemble somewhat those of
Tartar emetic, there being an excess of secretion in the tubes, and an inability to raise
the same.
But the last-named authority does not think it adapted, like Tartar emetic,
to reopen the hepatized air-cells. Hughes looks on Chelidonium as being particularly
valuable in pneumonia when the right lung is affected with involvement of the liver.
Ammonium carb. is another remedy which compares with Tartar emetic
when the symptoms point to a paretic condition of the vagi in the pneumonia of old
people. The pneumonia is usually attended with a copious expectoration, an inces-
sant cough from a sense of irritation in the larynx, and the patient is always worse
about 3 or 4 A.M.
Kali carb. has proved efficacious in the stage of resolution when both Tart.
emetic and Ipecac. had failed to relieve. It has been used mostly in children, when
considerable bubbling and rattling mucous rales are heard, with inability to raise the
tough phlegm; a tormenting cough, great dyspnoea preventing the child from sleep-
ing or drinking; stitches in the chest, and puffiness and cyanosis of the hands and
feet.
Sanguinaria ranks with Phosphorus and Lycopodium in the stage of gray
hepatization, and in pulmonary abscess. The general symptoms are those of hectic
or of typhoid pneumonia.
Rhus tox.—For pneumonia caused by exposure to wet and cold, for cases of an
adynamic type from the beginning, for pneumonia attended with an eruption, or for
an accompanying delirium due to deterioration of the blood, Rhus tox. is the first and
foremost remedy. Like Arsenicum, it bears no relation to uncomplicated pneumonia,
and like it the well-known symptoms calling for its employment in other states indi-
cate its choice here. Rhus is most useful when the onset of the disease is so indefinite
that to predict its development into typhus, or into pneumonia, is impossible. It is
even preferable to Phosphorus in the typhoid form of lung inflammation when the
latter is preceded and accompanied by bronchitis. The dyspnoea of Rhus is peculiar
in that it is occasioned by distension of the pit of the stomach. Other symptoms
are dry and hot skin; dry, raspy and dark tongue, with a triangular red tip; loss of
strength; sopor; dull hearing; subsultus tendinum, and involuntary passages of urine
and stool.
Belladonna, Hyoscyamus, and Opium are the chief remedies for the
delirium which so frequently complicates pneumonia, when it is due to arterial or
venous congestion. They can be considered merely as intercurrent remedies. When
the upper portion of the lung is involved, and the delirium is directly referable to cir-
culatory disturbance, and not to blood change, and especially if the head symptoms
are prominent from the start, Belladonna may be given at once, and with better effect
than Aconite. Hyoscyamus is specially valuable in hypostatic pneumonia, with de-
lirium, not so violent in form as that of Belladonna. There is less congestion, but
more nervous excitement, with talkativeness and hallucination, under Hyoscyamus.
Over the pneumonia of drunkards and of the aged, but more particularly in children,
when there is great cerebral depression from congestion and sudden threatening of
dissolution, Opium exerts a wonderful spell. The patient does not complain of pain;
the respiration is labored and slow, stertorous, or even entirely suspended; the face be-
comes rapidly cyanotic; the eyes are immovable, the lids half open; there is coldness
of the surface; an irregular or almost imperceptible pulse, and stupor.
Carbo veg. holds a high place in the therapeutics of the third stage of pneu-
monia. Great prostration accompanying the suppurative process is its chief and con-
stant symptom. The patient is listless, and is covered with a cold perspiration; the
pulse is feeble and rapid; the tongue is dry, without thirst; and the distressing cough
220
A SYSTEM OF MEDICINE.
is unattended by expectoration, although much rattling is heard in the chest. These
conditions supervene mostly in pneumonia of the aged, and it is much needed if em-
physema or right heart troubles coexist with the pneumonia. The distinction made
between the chest symptoms of Carbo veg. and Tartar emetic is that the former has
but very slight expectoration which affords no relief, while the latter has the ability
to raise some sputa, and feels the better for it.
Digitalis.—This remedy is of great value when irregularity of the pulse exists
in pneumonia. This is a very threatening symptom, and usually signifies a lesion of
the heart or aorta. It is most commonly met with among old people, and presages a
fatal termination. An irregular pulse is not an uncommon habitual condition to find
in those of advanced years. And among them the irregularity may disappear during
the height of the pneumonic fever. It again makes its appearance as the symptoms
abate, and indicates then a return of the normal condition. But if the irregularity
reappears without an abatement of the general symptoms, the outlook is very unfavor-
able, unless a remedy like Digitalis meets the case and affords speedy relief. Cactus
grand. is recommended for a like condition in pneumonia, when the sense of constric-
tion characteristic of the drug is present also. But alcohol is commended even more
highly when there is threatened failure of the heart, the circulation, and innervation.
The patient usually cannot take any kind of nourishment into the stomach, and his
small stock of vitality is rapidly being exhausted. In such cases stimulation is neces-
sary. Not more than an ounce or two of whiskey or brandy in the twenty-four hours
is required to gain the desired effect.
The room in which the patient lies should be kept at an equable
temperature of about 70° F. The air should be renewed, so as to
keep it fresh, and it should be moist as well as warm. It is not neces-
sary to place heavy coverings on the sufferer. The use of hot, damp
applications to the chest, especially when there is a complication of
pleurisy, is frequently advisable.
It is better to restrict the diet to the use of milk or some farinaceous
substance during the height of the fever, and as the general symptoms
abate and the pulse softens, beef-tea, broths, and soups may be sub-
stituted. Brown sugar dissolved in warm water has been found to be
much relished by infants, but if they exhibit any gastric irritability, a
tea made from parched corn will prove more suitable.
PHTHISIS PULMONALIS.
BY HERBERT C. CLAPP, A.M., M.D., BOSTON, MASS.
Synonyms. Pulmonary phthisis, pulmonary consumption, con-
sumption, pulmonary tuberculosis, tubercular disease of the lungs;
French, Phthisie; German, Schwindsucht.
Definition.-Phthisis pulmonalis (peiw, I waste or consume) is an
infectious disease, caused by the introduction into the system of a
micro-organism called the bacillus tuberculosis, and characterized by
the deposition of tubercle chiefly in the lungs, and its cheesy or fibrous
degeneration, as well as that of the inflammatory products which it
excites; also characterized by more or less hyperplasia of the pul-
monary connective tissue, thickening of the alveolar walls, and bron-
chiectasis, and by the calcification, or else softening and expulsion, of
DISEASES OF THE RESPIRATORY ORGANS.
221
the cheesy material, with more or less destruction (resulting in cavi-
ties) and retraction of the pulmonary substance.
Ætiology.—Recent investigations now enable us to conclude with
some confidence that the special cause of phthisis is the bacillus tuber-
culosis, the rod-shaped parasite discovered by Koch, which probably
oftenest gains an entrance to the system by the inhalation of pulver-
ized phthisical sputum, which, in most parts of the world, floats as
dust in the air, in such quantities that few can escape from breathing
it. This special cause, however, is powerless to act unless there be a
certain predisposition to the disease, either inherited or acquired; in
the latter case (by far more frequent) the susceptibility being de-
veloped under the influence of certain co-operating conditions, which
may properly be called the predisposing causes. Such are overwork,
mental depression, poor ventilation, excessive confinement indoors,
moisture of the soil, poor food, some trades and occupations, climatic
influences, general debilitating conditions, etc. These predisposing
causes, including heredity, probably never produce phthisis without
the fructifying influence of the specific cause, the bacillus. The co-
operation of both is as necessary in the production of each case of the
disease, as is the co-operation of the human father and mother in the
propagation of our race. There is now no real difficulty in harmon-
izing what have hitherto been more or less conflicting and troublesome.
facts. Phthisis must now be recognized as an infectious or contagious
disease. The reasons for these opinions will presently be given. The
evidence may be studied in groups, as follows: 1. Clinical observation
in man.
2. Clinical observation in cattle. 3. Experiments in inocu-
lating animals with tuberculous material. 4. Inhalation experiments
on animals with the same. 5. Feeding animals with the same. 6.
Koch's discovery of the bacilli tuberculosis.
This subject, which is necessarily here treated only in abstract, may
be investigated in greater detail in the writer's work, entitled, Is Con-
sumption Contagious? (published before Koch's discovery of the bacillus),
Boston, 1880, 2d edition 1882; in Belfield's Micro-organisms, New York,
1883; in Sattler's Tuberculosis, Cincinnati, 1883; and in recent period-
ical literature.
1. From the earliest times until a hundred years ago, phthisis was
generally believed to be a communicable disease. Hippocrates and
Aristotle testified to this belief among the Greeks, Galen considered it
dangerous to pass the whole day with a consumptive, Valsalva and
Morgagni avoided autopsies of persons dead with the disease from
fear of catching it, Riverius declared contagion to be the chiefest
cause of phthisis, etc., etc. The strong reaction which set in against
this prevalent belief in the last century, continuing undiminished till
after the middle of the present century, during which time infection
was regarded as an exploded theory, and which has only recently
222
A SYSTEM OF MEDICINE.
begun to give place to a belief in contagion, never gained a foothold
in Southern Europe, especially in Italy, where extreme views have
always prevailed, and consumptives have often been treated as if they
had the plague. The belief in infection, which has thus been more
or less prevalent in all ages, has never been based on the supposed
large number of cases which have been obviously communicated in
that way, for such cases have always been in the minority; but in all
times it has been occasionally noted that a perfectly healthy indi-
vidual, with no hereditary tendency to the disease, has contracted it
after a more or less intimate association with a consumptive, as for
instance, in the relation of husband or wife, roommate or particular
friend. Undoubtedly, brothers and sisters have frequently thus con-
tracted it from each other; but as skeptics would naturally declare
this to be the result of a common family constitution, if not directly
from hereditary tubercular taint, the believers in infection have gen-
erally laid more stress on cases where there was no blood relationship.
The following, from Herman Weber, may be quoted as a striking in-
stance of this class of cases, which, though not common, are still fre-
quent enough to excite the suspicions, not only of physicians, but also
of the laity.
"J- had seen his mother, two brothers, and a sister die of pulmonary con-
sumption, and had himself, on two occasions, had hæmorrhages when twenty and
twenty-one years old. He became a sailor, and was apparently in good health when
he left home, in his twenty-fifth year. He first married at the age of twenty-seven.
"He married four wives:
First. A woman belonging to a perfectly healthy family; she enjoyed excellent
health until her third pregnancy, when she began to cough and grow thin. She died
of consumption after her third confinement.
"Second. At the end of a year he remarried, the second wife having every appear-
ance of health; but, at the end of a year of conjugal life, she began to cough and spit
blood, and soon died of quick consumption.
"Third. The third wife belonged to an exceptionally healthy family, consisting of
a father, mother, four brothers, and two sisters, all living, and in good health.
"
When married, she was twenty-five years old, and continued to have good health
until her second pregnancy, when she began to cough and to have feverish turns.
She had two hemorrhages, and when I saw her, seven weeks after her second confine-
ment, she showed extensive lesions in the upper part of the lungs; also hectic fever
and profuse sweats. A month later she was taken with severe hæmorrhage, and died
shortly after, eight months from the appearance of the first symptoms.
"The autopsy revealed signs of pneumonic and tuberculous consumption combined,
to make use of an expression employed by the late Dr. Addison, who visited the
patient with me.
Fourth. The fourth wife, whom I also attended, had not a sign of consumption in
her family, and at the time of her marriage was twenty-three years old, and in the
enjoyment of perfect health. About thirteen months later, three months after her first
confinement, which had resulted happily, she began to cough, and had a little fever.
Then very clearly defined signs appeared, first at the upper part of the right, then of
the left lung; moreover, she coughed up blood, and had a slight pleuritic effusion.
"She experienced some relief during a voyage which she took to Melbourne, but
on her arrival there had a severe hæmorrhage, and died a short time after her return
to England, nine months after the appearance of the disease. The autopsy showed
extensive pneumonic and tubercular lesions in both lungs, as well as tubercles in the
intestines, spleen, and liver.
"At two different times, in 1854 and 1857, after the third wife's death, and during
the illness of the fourth, I had occasion to examine J. His general health was excel-
DISEASES OF THE RESPIRATORY ORGANS.
223
lent, and he assured me that he did not cough, and merely expectorated a little mucus
in the morning. The upper part of the left thorax was flattened, and percussion
showed it to be less resonant than the right; inspiration was less distinct, expiration
was prolonged, and from time to time rales were heard. He did not remarry, not
wishing to expose his choice to 'certain death.' He was apparently healthy, and con-
tinued to do active duty as a sailor until 1869, when he was forced to keep his bed for
some months, on account of a severe fracture; he then began to cough.
"The upper part of the right lung, which had until then been healthy, became
diseased, and consumption developed in the usual way, and caused the patient's death
in 1871. The autopsy showed cicatrization where the disease had first seized him,
and also more recent lesions."
Few physicians meet with such remarkable series of cases linked
together, but almost all must occasionally have, among their families,
single instances in which the origin seemed similar. No one within
the last thirty years has done more to dispel the cloud of skepticism
by clinical evidence than Dr. William Budd, who, after many years
of deep thought, announced in the London Lancet, in 1867, that he
considered tuberculosis to be a true zymotic disease of specific nature, in
the same sense as typhoid, scarlet fever, typhus, syphilis, etc., and that,
like those diseases, tuberculosis never originates spontaneously, but is
perpetuated solely by the law of continuous succession. Among other
evidence he cites the well-authenticated facts, that phthisis was un-
known in the South Sea Islands, and also in the interior of Africa,
before the whites came in contact with the population.
As an index of the state of feeling of physicians on the subject
shortly before Koch's great discovery of the bacillus tuberculosis, a
feeling therefore based on clinical observations, it may be stated that
out of 182 physicians who answered Dr. Bowditch's question in a
circular sent out under the auspices of the State Board of Health of
Massachusetts, in 1872, 110 considered consumption contagious, 45
held the opposite view, and 27 were doubtful. To a similar question
in a circular issued by Dr. Holden, of Newark, N. J., in 1878, out of
250 answers received, 126 were affirmative, 74 were negative, and 50
were doubtful. Dr. Holden, in making his report, added that it ap-
peared evident that those whose attention was much given to pulmo-
nary diseases, quite frequently inclined to a belief in contagion, while
those, however eminent as scientific men, who were interested espe-
cially in other directions, often doubted it. Although we thus see
that the majority of physicians, as far as consulted, appeared to be-
lieve in the infectiousness of phthisis, as a result of their observations.
in actual practice, we must yet acknowledge that clinical evidence
alone is not, and cannot very well be, absolutely decisive, however
strongly it may point in one direction or the other. For the influences.
to which any particular consumptive has been exposed, besides con-
tagion, are so varied (among them being many which are frequently
regarded as efficient causes), and the onset of the disease is so gradual
and insidious, and the period of incubation so uncertain, that from
clinical evidence alone it is not easy to decide the share of each agency
224
A SYSTEM OF MEDICINE.
in its production. Indeed, many who rely on the numerical method,
and are able to recognize only the claims of the majority, think they
have in statistics, as did Dr. Cotton in the Brompton Hospital for
Consumptives, conclusive evidence against contagion. Acknowledg-
ing, therefore, the indecisiveness of clinical evidence alone, we will
endeavor to strengthen it by the results of experiments on animals.
But before considering these, it will be interesting to take a rapid
glance at—
2. Clinical observation in cattle. For many years not a few veter-
inary surgeons have insisted that the perlsucht, which is now pretty
generally considered to be identical with human tuberculosis, is pro-
pagated by contagion among the bovine species; one animal acquiring
it either from inhaling the breath of a diseased fellow, or from eating.
food that had been contaminated by his secretions, especially by his
expectoration. Such authorities as Dupont, Cruzel, Viseur, Zundel,
and Fleming, hold strongly to the belief that this cause is efficient,
aside from all questions of heredity, ventilation, food, general care,
acclimatization, etc. Grad, veterinary surgeon in Alsace, in support-
ing this view, relates an interesting case, where six cows in succession.
had died in the same stall from phthisis, no other deaths occurring in
the establishment during the same time. The stalls were boxed in at
the head, to prevent interference. On Grad's recommendation, all the
woodwork was removed after the death of the sixth cow, the manger
and rack thoroughly disinfected, the spot left unoccupied for a time,
the stall again rebuilt and occupied by several animals in succession,
but no deaths from tuberculosis followed. The sputa, in which we
now know the bacilli can remain active for a long time, even in the
dried state, apparently spread the disease. Grad noticed many other
similar instances, and always recommended disinfection.
rare.
3. Experiments in inoculating animals with tuberculous material
were made by Dr. Villemin, of Paris, in 1865, and have since been
repeated by a multitude of experimenters. The animals selected were
not only rabbits and guinea-pigs, which often have the disease spon-
taneously, but also others, such as cats and dogs, among which it is
Animals inoculated with other substances, such as pus, etc., did
not become tuberculous, while those who received tubercle, as a rule,
took the local and general disease, though some more readily than
others, the susceptibility varying as it does in spontaneous tubercu-
losis. Villemin, after many experiments, came to the following con-
clusion: "Tuberculosis is the effect of a specific or virulent causal
agent,—in one word, of a virus. . . . . Introduced into an organism
capable of being affected by it, this agent is reproduced, and, at the
same time, reproduces the disease of which it is the essential principle
and the determining cause." The other experimenters in different
parts of the world confirmed the inoculability of tubercle, and Marcet,
DISEASES OF THE RESPIRATORY ORGANS.
225
of London, went so far as to assert that a doubtful case in man might
be corroborated or denied by the result of inoculating a guinea-pig
with his expectoration. But soon a practical difficulty arose. Wilson
Fox, Burdon Sanderson, Andrew Clarke, and others, claimed to pro-
duce tubercles by the inoculation not only of tuberculous, but also of
non-tuberculous or indifferent substances, such as putrid muscle, pus,
carcinoma, sarcoma, cinnabar, cuttle-fish powder, sand, glass, wood,
etc., and therefore denied the specificity of tubercle. This was a stum-
bling-block, indeed, and if proven would, of necessity, utterly demolish
the theory of the infectiousness of phthisis. Some asserted, however,
that these tubercles were not genuine pathologically, although they
might be histologically similar, but were simply inflammatory nodules.
But the strongest objection to these successes with indifferent sub-
stances was that they were not indifferent at all, being really accom-
panied by the germs of the disease floating in the air, and deriving
their origin from incarcerated animals, which either spontaneously or
experimentally had become tuberculous, and were at the time kept in
the same quarters, or else which had, previous to their death, con-
taminated those quarters with their secretions. If not in this way
derived, the germs might easily come from the tuberculous material
used for inoculation in the laboratory. (This explanation becomes
all the more plausible since the discovery of Koch's bacillus.) The
eminent pathologist Cohnheim, who, on account of his own and others'
successes with indifferent substances, had thrown discredit on Ville-
min's researches, acting on this suggestion, and excluding, as far as he
could, every possible source of tuberculous infection, now repeated his
experiments on rabbits and guinea-pigs, but not a single one became
tuberculous. He then magnanimously acknowledged his error and
became an infectionist. Fränkel also repeated his experiments in a
similar way at his private house, with absolutely negative results. The
other most prominent leaders in the experiments with indifferent sub-
stances-Wilson Fox, Burdon Sanderson, and others—have also since,
with true moral courage, retracted their previous utterances and ac-
knowledged the specificity of tubercle.
4. The inhalation experiments of Tappeiner, of Meran, in 1877, were
the first to attract general attention. He argued, that if consumption
is contagious, it must, in all likelihood, be conveyed by inhaling with
the breath fine particles of tuberculous sputa atomized into the air by
the patient's cough, and that this point could, to a certain extent, be
established, if animals could be made tuberculous in consequence of
the inhalation of such sputa artificially atomized. Therefore he caused
animals to breathe, for several hours each day, the air of a chamber
in which tuberculous expectoration from persons in the last stages of
consumption had been diffused by means of a common steam atomizer.
Almost invariably the animals became tuberculous, and in counter
VOL. I.-15
226
A SYSTEM OF MEDICINE.
tests, in which various indifferent substances were used, no tubercle
was produced. His experiments were repeated by Bertheau, Lippl,
Schweininger, Giboux, and others, with similar results. Giboux also
made other experiments with such air disinfected by being made to
pass through carbolized cotton, with negative results. On the other
hand, Schottelius and a few others, for a time, weakened the force of
these arguments by claiming to produce tubercles as well after substi-
tuting for tuberculous sputa that of bronchitis, and also pulverized
cheese, brain, etc. Those who have so constantly quoted Schottelius,
in opposition to the infectiousness of phthisis, will be interested to
know that Schottelius himself has lately acknowledged the fallacy in
his experiments, and has become an infectionist.
5. Feeding animals with tuberculous substances has been under-
taken by Chauveau, Klebs, Aufrecht, Gerlach, Guenther and Harms,
Bollinger, Tappeiner, Toussaint, Zurn, and many others. The results
were not so uniformly successful as when such material was inoculated
or inhaled; still, they left little room for doubt that it is possible for
absorption to take place from the alimentary canal, as well as from
the lungs and subcutaneous tissue, although probably with not the
same degree of activity. These experiments have a special and imme-
diately practical interest on account of the frequent use by us for food
of the meat and milk of tuberculous cattle, for it is now pretty well
established that the perlsucht is essentially identical with tuberculosis
in man, and is, moreover, a very common disease. These experiments,
if not absolutely conclusive, nevertheless indicate with great clearness.
the duty of government to institute rigid inspection of slaughter-houses
and of milch cows.
6. Koch's great discovery, in 1882, of the bacilli tuberculosis, of
itself did not prove that they, by gaining entrance into the system
and multiplying therein, were the cause of tubercle. Without further
demonstration, they might just as well have been the effect, the product
of tubercle. In order therefore to settle this point, it became necessary
for him to prove their causative action by skilfully isolating them by
ingenious methods from other minute organisms, as well as from their
gross surroundings; by cultivating them, generation after generation,
for months, on a specially prepared solidified gelatinous substance;
and then by invariably producing the disease in animals by the inocu-
lation of the cultivated parasites, purified from every particle of dis-
eased product or tissue, and by these only; the simultaneous inocu-
lation in other animals of the same culture substance without the
bacilli, or of any indifferent substance, always resulting negatively.
Koch's methods of cultivating micro-organisms were so much supe-
rior to those of his predecessors, that a brief abstract is here given.
Instead of using a fluid for culture (any fluid being open to objections),
he chose a solid, transparent nutritive soil in the form of blood-serum
DISEASES OF THE RESPIRATORY ORGANS.
227
gelatine, on which he could, when desired, actually see, through the
microscope, the multiplication of the bacilli in continuous succession,
and thus be sure that what he considered propagated from the original
stock, were not, as had undoubtedly often happened in the experi-
ments of others, extraneous bacteria. To begin with, the serum is
sterilized, so far as all living organisms are concerned, by daily heating
to 140° F. in a closed test-tube, or in the hollow of a microscopic slide,
an hour at a time for six days, and is then solidified by heating to 150°
for several hours. To this, in 6 or 8 test-tubes or slides, the tuberculous
substance is then quickly transferred with antiseptic precautions, a
small speck being carried on platinum wire just previously heated red
hot. The test-tubes are now kept constantly at a temperature of from
98 to 100°, and with a microscope of low power the colonies of bacilli
directly proceeding from the tuberculous substance may be seen in
about a week, their growth continuing for several weeks. In order to cul-
tivate the bacilli through many generations, he found it best to transfer a
few of them carefully on previously heated platinum wire to a fresh nu-
tritive soil in from ten to fourteen days. Thus he was able to cultivate
the bacilli and to have the evidence of his own eyesight that they were
really descended from those in the original substance, from generation
to generation, for over half a year, and it could have been done in all
probability for an indefinite period. They were thus entirely separated
and purified from their gross surroundings and from other forms of
bacteria. The cultivated bacilli not only had the same size, form, and
chemical reaction as those in the original tuberculous substance, but
they were also proved to be their progeny by having been seen to grow
from them by continuity of structure from generation to generation.
The next step was to prove experimentally that these cultivated bacilli
were really the cause of tuberculosis, and could produce it. Previously
to this, however, he repeated the inoculation experiments of Villemin
and others, with microscopical examinations for bacilli added; and
found that whenever he inoculated rabbits or guinea-pigs with sub-
stances containing bacilli, tuberculosis rapidly followed, the induced
tubercles likewise containing bacilli, but negative results followed the
use of indifferent substances, and also the use of tubercles soaked in
alcohol for a month, or dried for two months. Now, to prove
Now, to prove that the
results of these inoculations of tuberculous substances were actually
due to the bacilli contained in them, and not to any so-called virus
aside from these, he inoculated over 200 animals, not only rabbits and
guinea-pigs, which were known to be susceptible, but also cats, a dog,
white rats, pigeons, frogs, etc., some in the subcutaneous cellular tissue,
some in the peritoneal cavity, some in the aqueous chamber of the eye,
and some in the bloodvessels, with his isolated, purified, culture-bacilli ;
and in every instance tuberculosis followed, with reproduction of the
bacilli. He spent two years in these investigations before announcing
228
A SYSTEM OF MEDICINE.
his results in a modest paper, when he felt justified in asserting that
the bacilli were not merely the attendants of tuberculous processes,
but the real cause, and that there was no tubercle virus except the
bacilli. Koch also determined by culture-experiments that the bacilli
multiplied only at temperatures between 86° and 106° F., no growth.
taking place above or below these limits, and therefore concluded that
they naturally multiply only in the animal body. After having been
produced, however, he found by inoculation-experiments, that they
retained their activity for a long time, even when dried, as in the sputa
from phthisical individuals, in which, in the majority of cases, he found
them in large numbers. He considered that they were in all proba-
bility oftenest conveyed from one person to another by means of dried
and pulverized sputa wafted in the air, in which they have since been
found. From Koch's experiments and discovery, therefore, which have
never yet been disproved, it follows of necessity that pulmonary phthisis
is an infectious or contagious disease, and that the special agent which,
under favorable circumstances, is capable of causing it, is the micro-
scopical bacillus tuberculosis. Judging from the analogy of the other
contagious diseases, it is exceedingly improbable that phthisis is ever
produced in any other way, without the agency of this contagium.
vivum, which is so wide-spread throughout most of the earth, and re-
tains its activity so long, and is so constantly being reproduced in the
bodies of men and the lower animals, that we need have no difficulty
on the score of the improbability of its presence, in accounting for the
production of any isolated case in the most sequestered neighborhood.
From Koch's discovery the conclusion is also warranted that phthisis
is at first a local disease, and afterwards becomes generalized by the
migration of the bacilli from the parts of the lungs where they first
gained entrance by inhalation, to other parts of the lungs and to other
tissues of the body.
The Predisposition.-Having considered at some length the
agency of the special cause of phthisis, and our reasons for so consid-
ering it, it is now necessary to inquire into an equally important factor
-the predisposition of the individual. To some, when studying the
wonders of the germ theory, the temptation is so strong to dwell on
the marvellous properties and powers of a micro-organism in the pro-
duction of disease, that they overlook or belittle the condition of re-
ceptivity in the system, which is just as necessary for the growth and
multiplication of the germ, as the good soil of the parable was for the
development of the seed, which, if it had fallen in stony places or
among thorns, would have perished. In other words, the predisposition
is as necessary to the bacillus, and the bacillus is as necessary to the
predisposition, as to the theologian faith is to works and works to faith.
And yet the opponents of the contagiousness of phthisis, practically
disregarding the fitness of the breeding-ground, and looking only to
DISEASES OF THE RESPIRATORY ORGANS.
229
the supposed source of contagion, claim that it is clearly impossible
for this to be the cause, since so many are exposed and so few affected.
Yet, there is here nothing conflicting and incompatible. These same
physicians acknowledge scarlet fever to be contagious, and yet not
half the people in the world ever have it, although often exposed, and
they who do have it once very seldom have it the second time. The
germ is often there, but the predisposition is wanting. No epidemic of
cholera, small-pox, or yellow-fever has ever included in its victims the
whole population in any community, although all are presumably ex-
posed. Such would not be the case, if the same susceptibility every-
where existed. It is precisely the same in kind, though not the same
in degree, with phthisis. The bacilli are probably so profusely scat-
tered, that few escape inhaling or swallowing them. In some consti-
tutions which have the proper predisposition, or diathesis, either inborn
or acquired, they will find a fit nidus, and in others they will not, as
in botany some plants will thrive in one soil, but refuse to grow in an-
other. Inoculation experiments have abundantly shown that some
animals, rabbits for instance, are more susceptible to tuberculosis than
others, such as dogs; and culture experiments in laboratories have
proved that each species of bacteria takes most kindly to one particular
culture-medium, fluid or solid, in which it will flourish far better than
in others, which, however, may be preferable for some different species.
A certain degree of moisture, temperature, certain elements of com-
position, and so forth, are conditions necessary for the success of each.
Professor Tyndall, speaking generally, says: "Two bacteria germs, of
equal vital vigor, dropping from the atmosphere, the one into a neutral
or slightly alkaline, the other into an acid infusion, soon cease to be
equal in vigor; the life of the one is promoted, the life of the other
only tolerated by its environment. . . . . A germ, brought close to the
death-point, in a neutral or in an alkaline infusion may revive, while
in an acid one it may perish; just as proper nutriment may rescue a
dying man, while improper nutriment would fail to do so." Such
considerations as these ought to convince those who disbelieve the doc-
trine because clinical evidence shows that the majority of exposed
persons escape phthisis. It really requires very little more credulity
to believe that a healthy person, 35 years of age, has escaped the
contagion of phthisis, than that he has escaped from an attack of
scarlet-fever, millions of whose germs he has, in all probability, in-
haled without effect; for one-seventh of the deaths from all causes
are due to phthisis, to say nothing of those persons who have it and
recover; and some claim also that one-third of all the deaths of the
young adult population are from the same cause. Surely, this is fre-
quent enough. The susceptibility to contagious diseases varies, also,
in the same person at different times. Even to measles, to which there
is almost a universal susceptibility, some persons are exposed many
230
A SYSTEM OF MEDICINE.
times during a course of years before they succumb, and the same is
true of vaccination. It is altogether probable, also, that the suscepti-
bility to phthisis may be more easily acquired by persons previously
insusceptible, if particularly close and intimate relations are, for a con-
siderable time, held with a consumptive, as in the marital relation, for
instance. It is encouraging to think that the susceptibility to phthisis
may, at times, under favorable circumstances, be diminished or de-
stroyed, as, on the other hand, we know it may be acquired. It follows,
therefore, that we take a very one-sided view, and cannot reach correct.
conclusions, if, in the causation of phthisis, we consider only the germ,
and neglect the varying resisting power in living tissue, on account of
which the germs sometimes do, and sometimes do not, find a fit nidus
for their development and growth. Without the diathesis or predis-
position, innate or acquired, any individual may breathe in, or swal-
low with his food, millions of the bacilli tuberculosis with impunity,
while, with the diathesis, he will escape only if he can escape contact
with the bacilli, which in most parts of the world is impossible for any
considerable length of time. The practical conclusion necessarily is,
that remedies should be addressed, not so much to the destruction of
the bacilli, which is an almost hopeless task, but to the prevention or
removal of the diathesis. In order to know how to do this, it is
desirable to ascertain, as far as possible, what the co-operating conditions
are which strengthen or induce the diathesis or predisposition; in other
words,
The Predisposing Causes.-These may be classed as general and
local, and often co-operate with each other. The general, or constitu-
tional predisposing causes are those which affect the whole system, as
heredity or family predisposition, alcohol, poor food, poor ventilation,
poor climate, syphilis, debilitating conditions, damp soil, etc. Here
the functions of nutrition and assimilation especially suffer. The local
predisposing causes, such as bronchitis, pneumonia, pleurisy, dusty
trades and occupations, etc., act directly on the bronchi and alveoli, in-
ducing inflammatory lesions, with thickening and induration, which
probably form a fit nidus for the development of the bacilli.
Heredity, or, to put it more broadly, family predisposition, is most
undoubtedly effective in the causation of phthisis, although its influ-
ence has been greatly exaggerated, not only by the laity, but also by
physicians, who often confuse with its operation that of the various
insalutary surroundings of the child after birth.
Not only may
phthisical parents transmit to their offspring a susceptibility to the
disease, but also, a feebleness or vice of constitution which inclines to
phthisis may be inherited by the children of drunkards, or of those
who are affected by syphilis, cancer, nervous exhaustion, rheumatism,
etc. Many people have an opinion that the child of a consumptive
parent or parents is almost of necessity doomed, which is, of course,
DISEASES OF THE RESPIRATORY ORGANS.
231
erroneous. In such cases, careful attention to food, clothing, and gen-
eral hygiene will frequently forestall the disease.
Bad ventilation, and the constant breathing of a vitiated at-
mosphere, is universally admitted to be a strong predisposing cause of
phthisis. The disease is known to prevail more extensively among
those who have in-door occupations, such as printers, compositors,
tailors, milliners, seamstresses, etc., even when they are well fed, than
among drivers of teams, letter-carriers, and others who live much out.
of doors. Two-thirds of the patients in the Brompton Hospital, dur-
ing ten years, had indoor occupations. Phthisis is often twenty-five per
cent. more common in cities, especially in the most thickly populated
parts of these, than in the country where the air is purer. It particu-
larly prevails in prisons and barracks, where the food is generally
better than the ventilation; the bad air in crowded school-rooms often
has a bad effect.
Phthisis can often be developed in the lower animals by confine-
ment in close, poorly-ventilated apartments; and in the mining dis-
tricts of Cornwall and Devonshire, England, which are very healthy
above ground, one-half of the miners are said to die of phthisis.
Climatic influences have long been recognized. Some climates.
certainly favor and some oppose its development. In the temperate
zone it is far more common than in either the frigid or torrid, and
high altitudes (of at least 2000 feet) are especially antagonistic to
phthisical developments. The inhabitants of Iceland and of the in-
terior of Africa, in both of which places the disease is very rare, often.
acquire it on removing to the temperate zones. As a rule, phthisis is
apt to prevail particularly in those countries, and among those tribes,
where scrofula prevails. Moist climates, in which are frequent alter-
nations of temperature, are worse than dry climates in which the
temperature is uniformly either cold or warm.
Dampness of soil has been proved to be an undoubted predis-
posing cause of consumption, by the investigations of Dr. Buchanan
of England, the Registrar-General of Scotland, and Dr. Bowditch of
Boston, which show that the wet, heavy, clayey soils are the hotbeds.
of the disease, which greatly diminishes after proper drainage. Not
only is this true of townships, but also of individual houselots. Near
a lot of this character may be others with dry, sandy soil, especially if
more elevated, on which the disease rarely appears.
Poor food has a decided influence in the development of the tu-
bercular diathesis. Not only is this seen among the lower classes, es-
pecially in times of business depression, when food is scarce and dear,
but also among those children of the rich who are allowed to eat much
candy and cake, and indigestible substances generally. For it is not
so much the amount and quality of the food taken into the stomach,
as that which is properly digested and assimilated, which builds up
232
A SYSTEM OF MEDICINE.
the system; and mal-assimilation and mal-nutrition is the important
point. It is probably by diminishing the appetite and interfering with
nutrition that some of the other causes act.
Age is also to be considered in this connection. Although phthisis
may occur at any age, and affect the very young or the very old, yet
it is by far most common in early adult life, almost one-half of the
entire number of cases occurring in persons between twenty and thirty
years of age. The next most common decade is from thirty to forty
years, the next forty to fifty years, and the next ten to twenty years.
The reason for this we cannot tell; it is a part of the predisposition.
Acute phthisis is more common in young, and the chronic disease in
older persons.
Sex does not seem to exert any special influence in the production
of the disease. Authorities differ as to the preponderance of males or
females.
Debilitating diseases and conditions have a very decided influ-
ence. Among these may be classed miscarriages, parturition and
over-lactation in feeble women, typhoid fever, syphilis, mental depres-
sion, extreme bodily exercise, and the cessation of habitual discharges,
as from anal fistula or old ulcers; indeed, anything which is per-
manently exhausting.
Local predisposing causes of phthisis, like general causes, are not
sufficient of themselves alone to produce the diathesis. In each case
there must be added an indescribable something for them to work
upon; else few persons would escape.
Dusty trades and occupations have been shown by Dr. Green-
how to furnish an obvious source of irritation to the air-passages, and
to be quite active agents in the development of phthisis. Stone-masons,
needle-grinders, cotton and wool carders, porcelain workers, coal
miners, potters, and others who are constantly obliged to inhale fine
particles of stone, iron, cotton, wool, flax, clay, straw, etc., are particu-
larly subject to the disease. Such particles have frequently been rec-
ognized in the lungs by chemical and microscopical examination in
the midst of masses of real tubercle, with softening, cavities, etc. Dr.
Greenhow estimated that 45,000 deaths occurred from the inhalation
of such kinds of dust in England and Wales.
Bronchitis, pneumonia, pleurisy, hæmoptysis, and chronic
pharyngitis, are all by many, especially since Niemeyer espoused
these views, considered as local causes of phthisis, while Louis and his
many followers have contended that they have no particular causative
action. Flint has argued, in his work on phthisis, from a large clinical
experience, that these diseases have been antecedent to only a very
small proportion of his collected cases of phthisis; and also that from
a consideration of separate collections of these individual diseases,
very few of them appear to eventuate in phthisis; and that if this
DISEASES OF THE RESPIRATORY ORGANS.
233
association is more than a coincidence, these diseases only serve to
determine the local manifestion, the cachexia already existing; they,
in other words, acting the part of the match when everything is ready
for the explosion. He thinks that the new doctrine of the special
causative agency of the bacilli, in which he seems to be a firm believer,
militates against the direct causative agency of these affections as well
as of traumatism.
Deformity of the chest does not, as some have supposed, particularly
favor the production of the disease. Emphysema, asthma, and also those
cardiac lesions which interfere with the proper aëration of the blood,
act, to a certain extent, as preventives to phthisis. Marriage and
childbearing, instead of acting this way, as some have claimed, really
hasten the progress of the disease in those predisposed to it.
Pathology and Pathological Anatomy.-The modern doctrine
of the bacillus tuberculosis enables us to introduce a little more order
into the confusion which previously attended the teaching on the pa-
thology of phthisis. Before the promulgation of this doctrine, the
most commonly accepted division of the varieties of this disease,
based on the authority of Virchow and Niemeyer, had been a trifold
one, into caseous, tubercular, and fibroid phthisis. Caseous phthisis was
characterized by the cheesy degeneration of the inflammatory products
of catarrhal pneumonia, in consequence of some "vulnerability" of con-
stitution, followed by the liquefaction and expulsion of these products,
and consequent injuries to the lung substance. Here tubercle played
a secondary part, and was not supposed to be introduced until the
disease was well advanced. The key to the proper understanding of this
form lies in Niemeyer's famous axiom, that the greatest danger which
hangs over such a patient is the possibility that he may become tu-
berculous. This form, being inflammatory, was often called cheesy
pneumonia, broncho-pneumonia, chronic catarrhal pneumonia, etc.
The second variety, on the other hand, tubercular phthisis, as its name
indicated, was dependent from the beginning on the deposit of tuber-
cle as its starting-point. Here the tubercle-granulation was the excit
ing cause, and not the consequence, of the catarrhal pneumonia with its
checsy degeneration; the same softening, expulsion, and destruction
of lung substance followed. The third variety, fibroid phthisis, was
characterized principally by hyperplasia of the connective tissue, and
retraction of the lung, and by atrophy and degeneration of its peculiar
substance, together with cavities resulting from bronchiectasis. Here,
too, tubercle played a secondary part, not being introduced into the
first act.
This division must now be changed; for enough has been said in
the section on ætiology to prove that tubercle is the starting-point, the
fons et origo of all forms of phthisis. No one variety of phthisis is dis-
tinctively tubercular. Pulmonary phthisis is synonymous with pul-
234
A SYSTEM OF MEDICINE.
monary tuberculosis. Besides, on a more careful examination it was
found that Virchow's caseous pneumonia was not, at its commence-
ment, such a purely inflammatory process as he thought, for from the
beginning tubercles can be found alongside of the inflammatory pro-
ducts, and also in the vanguard with them as these advance; a fact
which does not support the theory that tubercles are the result of a
retrograde metamorphosis. They also accompany all stages of fibroid
phthisis. The latter being quite distinctive, both in its pathology and
clinical history, must remain as one variety of phthisis, but the caseous
and tubercular varieties must be coalesced and form the other great
division, to be called caseous or catarrhal phthisis, there being now no
longer any reason for their separate maintenance, tubercles originating
both. It is not to be supposed that each of these two great varieties is
entirely independent of the other, there being in every case of fibroid
phthisis more or less of the cheesy products, and there being in every
case of catarrhal or caseous phthisis more or less of hyperplasia or in-
duration of the connective tissue, with its results. We simply mean
that in one case one feature greatly predominates, and in another case
the other feature, enough to warrant the use of a distinctive name,
especially as the symptoms of the two forms also greatly differ. Acute
miliary tuberculosis, the tubercles being pretty uniformly and exten-
sively diffused throughout the system, not being a lung disease, but a
general affection, does not come up in this place for consideration.
The chief characteristic, then, of phthisis is tubercle, which, in the
miliary form, is a small, grayish-white, semi-transparent, non-vascu-
lar, roundish granulation, smaller than a millet-seed, and just large
enough to be visible, generally, to the naked eye; at its periphery hav-
ing many round cells like leucocytes, larger cells, epithelioid, like for-
mative cells of granulation tissue nearer its centre, and at its centre.
one or more very large cells with numerous nuclei, called giant cells.
These cells are very apt to undergo caseous necrosis, beginning at the
centre of the tubercle, so that at the latter place the structure may be
completely obscured. Fatty degeneration often occurs, and occasion-
ally, though rarely, fibrous transformation. These tubercles, probably
both because they have a specific virus and are foreign bodies, in the
great majority of cases, excite inflammation around them, and the
inflamed tissues and inflammatory products joining with them serve to
make them seem much larger than they really are. Inflammation may
also be excited at some little distance from them. They continually
spread and propagate themselves, exciting inflammation about their
new locations in bronchi, alveoli, blood vessels and interstitial tissue,
and both they themselves, and the products of inflammation induced
by them, undergo caseous degeneration, as a further and more severe
result of that specific irritant, the tubercular virus; thus, also, evidenc-
ing infective character. The lymphatics and veins are a favorite
DISEASES OF THE RESPIRATORY ORGANS.
235
channel for their progress. The gradual coalescence of these little
patches of caseous necrosis form those larger masses of dry, yellowish,
cheesy-looking material, formerly called crude or yellow tubercle, as
distinguished from the gray granulation, which is also the infiltrated
tubercle of Laennec. We have about gone back to the views of Laennec,
with this exception: he considered the essential cause of tuberculosis to
be a particular state of the constitution; we recognize this latter simply
as a preparatory state, and require in addition the seeds of the disease,
the bacilli tuberculosis. Phthisis is no longer a general disease with
a local manifestation in the lungs, but at the outset it is a local dis-
ease, although the system may eventually become more or less in-
fected.
Miliary tubercles first form, says Rindfleisch, in the walls of the
smallest bronchi, where they open into the alveolar passages. It is here,
then, that the bacilli, wafted on the air in the form of dried, pulverized
sputa, first find a successful lodgment, if the dyscrasia exists. If not,
they are rendered inoperative. It has been spoken of as probable that
the reason why the apices are the first affected is that they are the
least expansible portions of the lung, and that in persons who do not.
breathe deeply the air is, consequently, apt to stagnate in them, thus
giving the bacilli a better chance to find a fit nidus.
The tubercular virus, operating on the bronchioles, produces not
only a deposit of miliary tubercles there, but also a chronic catarrh of
their mucous membrane, which is also often accompanied by ulcera-
tion of the latter (resembling tubercular ulcers in the intestine), the
little depressions thus formed appearing to the naked eye like saccular
dilatations of the bronchioles. The tubercles are deposited, not only
in the bronchioles in immediate proximity to the lobules, but for some
distance beyond. From these deposits the disease tends to spread
mostly in one of two directions—either to the alveoli, the inflammation
being principally catarrhal, or to the surrounding connective tissue,
and thence into the general connective tissue of the lungs, the inflamma-
tion producing new formation and induration of this tissue. We say
mostly, because in all cases there is more or less of both kinds of
spreading, but in one the extension to the alveoli predominates, and in
the other the extension to the connective tissue predominates. This is
the basis of the division into the two great classes of phthisis already
mentioned the catarrhal or caseous and the fibroid. In both, a peri-
bronchitis is first set up by the deposit of tubercles, and inflammation
and induration of the connective tissue in the immediate neighborhood
of the little ulcers of the bronchioles already mentioned. Why the
spreading should sometimes take place in one direction and sometimes
in the other it is impossible to say, excepting that it probably depends
on individual peculiarities. That to the alveoli, producing cascous
phthisis, is by far more common, and will first be explained.
236
A SYSTEM OF MEDICINE.
Caseous or Catarrhal Phthisis.-The catarrhal inflammation
of the alveoli, already spoken of, leads to their filling up with large
epithelioid cells, and rarely with the small round cells and fibrin of
hepatization. The alveolar walls are often so much swollen by their
infiltration and inflammation, that it is difficult to mark out their
boundaries. The walls of the little blood vessels are also so much
swollen by their infiltration with tubercles and inflammation, as to
rupture occasionally from weakness and cause hæmorrhage. Many
blood vessels at the apex of the lung becoming occluded, the pressure
in the rest becomes greater. The infiltration with miliary tubercles
of all these structures-bronchioles, peribronchial connective tissue,
alveoli, and blood vessels, together with the products of inflammation.
-causes a grayish-colored solidification of the lung tissue in larger
or smaller areas, which have a distinct lobular arrangement, like
bunches of grapes, depending on the distribution of the small bronchi.
These almost always form first at one of the apices; at the left apex
a little oftener than at the right. After a while the solidified struc-
tures, including the tubercles, undergo a caseous necrosis, when the
grayish color gives place to an opaque yellow or white appearance,
with the friability of cheese. This necrosis begins in the central part
of each small condensation, and works outward toward the periphery.
Under the microscope the outlines of the alveoli are almost, if not
quite, obscured, and nothing is seen but fine homogeneous granules.
If the patient gets well, from this time the caseous mass becomes encap-
sulated, dried, infiltrated with lime salts, and converted into a putty-
like material, or chalky mass, which remains harmless in the lungs
for years or for the rest of life, or sometimes becomes absorbed. Un-
fortunately, this is the exception rather than the rule. Oftener the
caseous material softens and breaks down into a greenish-yellow or
gray, creamy, homogeneous fluid, in which may be found fibrils of the
elastic tissue of the lungs. Thus cavities in the lung substance are
formed, and their broken-down, liquefied contents are discharged by
ulceration into one or more bronchi, whence they make their way
through the trachea and larynx, and are expectorated. The cavities
are at first small, but soon increase in size by the coalescence of neigh-
boring softenings. They extend as long as they are bounded by soft-
ening tubercle and caseous masses, their walls being ragged and
ill-defined. Later, a partial smoothing of their walls may take place by
the formation of a connective-tissue lining, which constantly secretes
a greenish-yellow pus, which is sometimes fetid on account of decom-
position from the presence of air. These cavities are often traversed
by trabeculæ, representing branches of the pulmonary artery which
have survived the general necrosis, some of them being obstructed and
some partially pervious, with aneurismal dilatations of their weakened
walls. From the rupture of these aneurisms, either in the traversing
DISEASES OF THE RESPIRATORY ORGANS.
237
trabeculæ or else in the walls of the extending cavities, come the fre-
quently copious hæmorrhages of the latter stage of the disease, hæm-
orrhages which would be still more copious, were it not for the nar-
rowed calibre of the blood vessels. When the disease approaches the
pleura, a dry inflammation generally takes place over a greater or less
extent, gluing the pleural surfaces together so firmly, that at a post-
mortem examination, in tearing them apart, there is great risk of
opening into one or more cavities. If, however, as occasionally hap-
pens, especially in acute cases, a cavity comes to the pleural surface
at a place where vascular adhesion has not taken place, necrosis and
giving way of that portion of the pleura occurs, and the escape of the
contents of the cavern into the pleural cavity gives rise to a pneumo-
thorax and also to an acute attack of pleurisy with effusion. Thus a
pneumothorax, depending for its production on the absence of pleural
adhesions, is more apt to occur in the lung least affected. The great
pathological law for the extension of a tubercular deposit is, that at
first one apex is attacked, and the disease gradually extends down-
wards. After it has made more or less progress, however, the same
process is repeated in the other lung. The disease, although it gener-
ally exists in both lungs after the patient has been sick for a good
while, is, therefore, always further advanced on one side than on the
other. The rule that the upper portions of the lungs are attacked first
is almost universal. It is exceedingly rare for tubercular trouble to
begin in a lower lobe.
It must be remembered, as before stated, that with the changes just
described in caseous phthisis, more or less inflammation and indura-
tion of the general connective tissue takes place. Such induration,
forming the most prominent feature in another class of cases of phthisis,
will now be discussed at length in connection with the pathology of
Fibroid Phthisis.-This has been often called chronic interstitial
pneumonia, or cirrhosis of the lung, and in its typical manifestations.
is not nearly so common as the caseous form, although its essential
features enter to some extent into almost every case of phthisis. As
with the other variety, the tubercular deposit and inflammation begin
in the small bronchial tubes, the mucous membrane of which is at
first dark red and later of a slate color, and contains here and there
tubercular ulcers. The sub-mucous connective tissue of the bronchi
is greatly thickened, containing round cells, and their muscular layer
is at first hypertrophied, but afterwards softened and dilated. Peri-
bronchitis is produced.
The connective tissue of the healthy lung lies mostly around the
bronchi, around the blood vessels, between the lobules, and under the
pleura, and is all more or less intimately connected by means of the
lymphatics. Through the lymphatics then, to all this network of in-
terstitial lung tissue, the tubercular poison in this form of the disease
238
A SYSTEM OF MEDICINE.
is apt to spread from its first location in the bronchi, in just the same
way that Hamilton has shown how coal-dust or any other foreign ma-
terial, after inhalation, may be carried about and deposited in the in-
terstitial texture of the lungs. In fact, in this form of the disease, the
inhalation of coal-dust or fine particles of stone, iron, cotton, flax,
wool, clay, etc., have undoubtedly much to do in co-operating with the
bacilli to produce the disease. The tubercular virus thus introduced
excites inflammatory induration and new formation of dense con-
nective tissue, containing round or spindle cells. On section, this shows
as trabeculæ of very firm, almost cartilage-like tissue, traversing the
lung in the direction of its root, of a grayish color, with patches of
brown pigment, and with little vascularity. In all stages may be
found miliary tubercles, which here, following the fashion of the
changes in the connective tissue, undergo the fibroid transformation.
In all such tubercles, no matter how deeply seated, as well as in the
tubercles in the caseous form, have been found under the microscope
the bacilli tuberculosis.
ease.
Bronchiectasis is one very striking feature of this form of the dis-
Several forces combine to produce this dilatation of the tubes.
The ulcerations in the mucous membrane of the bronchi and the soft-
ening of their muscular layers have already been described. The
thickened pleura, which in this form of the disease sometimes acquires.
the remarkable thickness of a half inch, is firmly adherent to the chest
walls, and is connected by the toughened, constantly contracting inter-
stitial tissue to the peribronchial induration, which pulls out the weak-
ened bronchial wall and also drags in the chest wall, especially at the
apex, a sinking in which is a very common feature in the disease.
Another force is that of the expiration in coughing. Still another is that
of inspiration, by compensation, on account of the general contraction of
the lung. The cavities of bronchiectasis are either fusiform or saccu-
lated, the latter predominating. They have a distinct lining mem-
brane, which is often directly continuous with the bronchial lining
membrane. Sometimes also the peribronchial connective tissue con-
tracts concentrically and obstructs the bronchus, in which the secre-
tions may accumulate and cause dilatation of the tube beyond the
obstruction. The walls of these, as of other bronchiectatic cavities,
generally contain ciliated epithelial cells.
The constant contraction of the newly-formed connective tissue also.
compresses many of the alveoli, of the blood vessels, and of the bron-
chioles. Compensatory emphysema naturally results on account of
the dilatation of others of the alveoli, to make up for those that are
obliterated. The compression of the little arteries and of the bronchi-
oles results in an atrophy from lack of blood supply, and a collapse of
lobules (atelectasis). In the collapsed lobules a catarrhal inflamma-
tion takes place, and cheesy masses form, soften, liquefy, and are
DISEASES OF THE RESPIRATORY ORGANS.
239
expelled from the cavities thus produced, as in caseous phthisis.
Thus we see again that these two forms of phthisis are intimately re-
lated to each other, but that in one the cheesy, catarrhal process pre-
dominates, and in the other the fibroid. Between these two typical
forms may be met in practice all degrees of transition. In the early
stages of fibroid phthisis, the lung, especially in its upper lobe, on sec-
tion, seems dotted over with small, isolated, hard, nearly black masses,
which are found to be the small bronchi surrounded by indurated and
pigmented connective tissue containing tubercles. At a later stage, the
lung seems greatly shrunken in size, a result of the shrinkage being
seen not only in a retracted chest, but also often in a lateral curvature
of the spine. Although not entirely confined to one lung, the affection
is much more one-sided than is caseous phthisis. The principally
affected lung being so much retracted, the other lung is apt to be
drawn over towards it. The heart also is more or less dragged out of
place, and suffers organic alteration from the compression and closure
of the pulmonary arterioles. For, the circulation in the lung being
obstructed to so great an extent, the right cavities, as a natural result,
become dilated, a stasis of the venous circulation follows, the liver en-
larges, the kidneys are congested, albumen appears in the urine, and
dropsy is added. Fibroid phthisis is said to be often preceded by
pleuritic effusion, pneumonia, or pleuro-pneumonia.
The bronchial glands in both forms of phthisis, as a rule, contain tu-
bercles. In the caseous form they enlarge, caseate, sometimes soften,
sometimes calcify. In the fibroid form, they undergo fibrous transfor-
mation and become dense, hard and pigmented.
The mucous membrane of the larger bronchi, of the trachea, and of
the larynx may also be the seat of tubercular ulceration, which proba-
bly arises from the passage over them of the virulent, tubercular,
broken-down lung substance during expectoration. The same sub-
stance is often swallowed, and produces tubercular ulceration of the
intestines. The occasional presence in phthisis of tubercles in the
liver and kidneys and urine and genital organs (although rare in com-
parison with their presence in those parts in acute miliary tuberculo-
sis), is probable evidence that the bacilli have been transported by the
blood, especially since the recent discoveries by Ponfick of tuberculosis
of the thoracic duct, by Weigert of tuberculosis of the veins, and by
Weichselbaum (Wiener med. Wochenschrift, No. 12, March 22d, 1884), of
tubercle bacilli in the blood.
Physical Signs.-These, which are of the utmost importance in
diagnosis, will be considered with especial reference to the three stages
of the disease-first, the incipient or stage of consolidation; second, the
stage of softening; and, third, the stage of excavation. One set of signs
in any of these stages directly indicates the physical condition of solidi-
fication of the lung, another set a cavity, and other signs certain acces-
240
A SYSTEM OF MEDICINE.
sory conditions, as circumscribed bronchitis, pneumonia, or pleurisy.
When one lung only is affected, the signs are to be heard, as a rule, at
the apex at first; and as they in their progress gradually reach the
parts below, signs of commencing trouble at the other apex may be
expected.
First Stage.-Inspection is not often to be depended upon here. The
percussion at the apex is dull in all degrees, from that which is almost
indistinguishable from the normal sound to that which is very decided.
Slight degrees of dulness at the left apex must always be counted;
but owing to the occasional existence of a very slight amount of dul-
ness at the right apex in health, considerable judgment is necessary in
making a decision as to its importance in disease, a judgment which
is only to be based on experience; in some cases an opinion should be
reserved for a future examination; beginners often make allowance
for too much dulness. The dulness may be either in front or behind.
In some cases, a secondary emphysematous condition may be set up in
lobules near the deposits, which may give rise to a vesiculo-tympanitic
or exaggerated resonance on percussion; or this resonance may so
modify the dulness, that a kind of balance results, which may sound
very like the normal vesicular resonance. The respiration is weakened
or broncho-vesicular, occasionally jerking. The vocal resonance, bron-
chial whisper, and vocal fremitus are increased. The slight possible
normal increase on the right side must be allowed for. These are the
signs of a small portion of the lung solidified by a tubercular deposit.
There need be of necessity no rales. If these exist, they are heard at
the apex, and do not primarily but only inferentially indicate phthisis;
for they depend for their production on a local secondary bronchitis,
pneumonia or pleurisy, which is excited by some irritation, and the
most likely irritation at the apex is a tubercular deposit. If this sec-
ondary affection is a circumscribed bronchitis, or a spasm of the tubes,
sibilant rales are heard; if a circumscribed capillary bronchitis, sub-
crepitant rales; if a circumscribed pneumonia, crepitant or crackling
rales; if a circumscribed dry pleurisy, rubbing or crumpling friction-
sounds. Any rales, in fact, heard at one or the other apex, are suspi-
cious. A tubercular deposit occurs somewhat oftener at the left apex
than at the right, the proportion being about five to three.
Second Stage. On inspection, a certain amount of flattening and defi-
cient expansion at one apex can be seen. Mensuration often shows a
decided decrease in size. On percussion of the affected side, more or
less dulness is found at the upper part, owing to the solidification, and
sometimes exaggerated resonance from a coexisting emphysematous
condition. The respiration is bronchial or broncho-vesicular in propor-
tion to the amount of deposit, or weakened, and sometimes jerking, if
the tubes are more or less obstructed. The heart-sounds are heard
more distinctly transmitted through solidified than through normal
DISEASES OF THE RESPIRATORY ORGANS.
241
lung texture. The same rales may be heard as in the first stage, and
indicating the same secondary, circumscribed affections at the upper
part of the chest. In addition, fine and coarse bubbling rales are pro-
duced by the breaking down and liquefying of the tubercular deposit.
These are heard better in the morning before much expectoration
takes place. If there is sufficient solidification, bronchophony and
whispering bronchophony are heard; if not, the vocal resonance and
whisper are increased. Generally, during this stage, signs of commenc-
ing trouble are to be heard at the other apex.
Third Stage.—Softening has now proceeded to such an extent that
cavities form, generally in the upper part of the lung. Around them
may be heard the signs of solidification. The upper parts of the lung
fall in so much that the clavicle seems very prominent on inspection, and
the deficient expansion and diminished size on mensuration are far
more noticeable than in the second stage. On percussion over the
cavity, the resonance is tympanitic, and occasionally cracked-metal or
amphoric. When the cavity is full of morbid products, however, as
often in the morning before expectoration, dulness takes the place of
these sounds. The respiration is cavernous, if the cavity is of good
size and has been emptied by free expectoration. If small, the neigh-
boring bronchial or broncho-vesicular respiration may predominate.
The rales, unless the cavity is full, are gurgling, and are very distinc-
tive of this stage. The vocal resonance is cavernous pectoriloquy and
whispering pectoriloquy, or amphoric. The vocal fremitus is often in-
creased. The heart may be dragged out of place by shrinking of the
lung, and its new position recognized by palpation, auscultation, and
percussion.
Symptomatology.-Phthisis is often developed in a very insidious
manner. Long before there are any distinct evidences of the disease,
indications of deterioration of the general health and loss of constitu-
tional vigor may manifest themselves. Lassitude, diminished appe-
tite, indigestion, daintiness, aversion to fatty substances, irregular
movements of the bowels, cold feet, pallor, loss of weight, are supposed
by some to indicate what they call a pre-tubercular stage. But these
symptoms, occurring in a previously healthy person, although they
may put us on our guard, yet certainly cannot be considered as decided
evidence of approaching phthisis, since they so often occur without
this disease as a sequence. It is always easier to look back and see
their connection with phthisis after its full development, than to look
ahead and from them to predict it with any certainty. Such an assem-
blage of symptoms, however, so often ushering in the disease, it be-
hooves us to watch very carefully. A more decided symptom, which
sometimes attracts attention and sometimes does not, is a cough, at first
slight, dry and hacking, afterwards with expectoration of mucus, which
gradually becomes more abundant. Other symptoms follow sooner

VOL. I.-16
242
A SYSTEM OF MEDICINE.
or later, such as emaciation, pallor, weakness, pains in the chest, a
quickened pulse, hæmorrhage, chills, a rise in temperature, with the
hectic flush in the afternoon, night-sweats, quickened respiration, in-
digestion, a white tongue, torpid bowels, and scanty urine. Of these
the constant cough and increasing emaciation are the most common
and prominent features. As the disease progresses, the expectoration
becomes more abundant and purulent, and contains filaments of lung
tissue, the cough increases in severity, diarrhoea sets in, in women
menstruation is diminished or suppressed, the emaciation rapidly
progresses, hoarseness, or even complete aphonia appears, the fingers.
are clubbed, the feet and ankles are swelled, and the patient dies of
exhaustion, sometimes of suffocation.
Such, in brief, is an outline of the course of phthisis. Some of its
symptoms may be profitably studied in detail.
The cough of phthisis is never entirely absent, and varies in severity
with the extent of the disease, increasing with the latter's aggravation
and subsiding with its arrest. At first dry or hacking, it is frequently
for a long time unnoticed by the patient, who, unless his attention ist
particularly directed to it, will often declare that he has no cough. As
it increases in intensity, it becomes moister and is sometimes parox-
ysmal, occasionally inducing vomiting. Although it may be particu-
larly violent and distressing in some cases, yet, as a rule, the cough of
consumption is not extremely severe. After the disease has made some
progress, it is by far more common in the morning, owing to the irrita-
tion of the morbid products accumulated in large quantities during
the night, the patient going through a regular clearing-out process;
this is repeated, to a lesser extent, in the evening, shortly after lying
down. After the supervention of laryngeal complications with ulcer-
ation of the vocal cords, the cough becomes hoarse and greatly altered
in tone. With these changes and those produced by large cavities in
the lungs, the character of the cough seems to many sepulchral.
The expectoration at the beginning of the disease, when there is
any expectoration, is a glairy mucus from an accompanying catarrhal
process. In most cases, it does not commence until the cough has
continued for some time. Dots and streaks of blood are interspersed
when the cough is paroxysmal and violent. When the lung texture.
begins to break down, shreds of clastic tissue may be found upon mi-
croscopical examination of the sputa. When cavities have formed,
the sputa becomes round, compact, grayish or yellowish masses with
ragged edges, often called nummular, which sink in water, and contain
amorphous granular matter besides cells and elastic tissue. Often
lumps of cheesy material with an offensive odor are expectorated.
Now and then fragments of calcareous or chalky masses are coughed
up, which may even equal a pea in size. Although the expectoration
of such stony bodies is rare, they are frequently found in the lungs at a

DISEASES OF THE RESPIRATORY ORGANS.
243
post-mortem examination, surrounded by a thick capsule of cicatri-
cial tissue, which prevents their escape. While in such cases they may
indicate a curative tendency in an old phthisical process, yet when
they do escape and are expectorated, the indications are, from the rup-
ture of the capsule, that softening is now progressing. As the disease
advances, the expectoration contains increasing quantities of pus, which
comes to a great extent from the walls of cavities. Collecting in these
cavities, it is now and then expelled in great quantities during parox-
ysms of coughing. This pus often has a greenish or dirty-gray color
and an offensive odor from its putrefaction. The quantity of the ex-
pectoration will vary greatly with the extent of the bronchial catarrh
and the size of the cavities.
Hæmoptysis, or the spitting of pure blood-not of blood-streaked
expectoration—is of very common occurrence in all stages of phthisis ;
and, although usually quite alarming to patient and friends, is rarely
of immediate danger to life, except when the disease is far advanced.
At or near the beginning, before other symptoms have become prom-
inent, it forms quite an important element in the diagnosis. It may
be the first indication of approaching trouble, the patient, previous to
the attack, being apparently in the best of health. Some have con-
sidered that such a hæmorrhage really precedes and is the cause of
phthisis, blood remaining in the bronchi and alveoli, and by its irri-
tation starting up a pneumonic process, which undergoes the cheesy
transformation. Actual experiments on animals render this unlikely.
Decidedly the more probable view, especially since the discovery of
the parasitic origin of phthisis, is that the disease of the arterial coats,
which allowed the escape of blood, was really of a tubercular nature,
even though positive symptoms had not declared themselves; and sev-
eral autopsies have confirmed this view. Additional confirmation
comes from the clinical fact that two-thirds of such hemorrhages are
not immediately followed by any phthisical process; an interval of
weeks, months or several years intervening. Indeed, phthisis may never
follow a hæmorrhage from the lungs, which cannot be considered pa-
thognomonic of the disease; still, it is well to remember that when
hæmoptysis occurs in a patient free from organic heart disease, either
phthisis already exists, or, in the great majority of cases, will sooner
or later follow. More often, hæmoptysis is not the first symptom of
the disease, even in those cases where, from its startling nature, it at
first seemed so; for, the patient or his friends, on careful retrospection,
can now generally remember a previously-unnoticed slight cough, at
least, as its predecessor. Except in the last stage of the disease (and some-
times even then), the hemorrhage comes from the bronchial mucous
membrane, particularly that of the smaller tubes, on account of the
rupture of minute bloodvessels. The alarming hæmorrhages, often
causing death from syncope or suffocation, which occur in the last

244
A SYSTEM OF MEDICINE.
stage of the disease, generally come from blood vessels in bands of
pulmonary tissue, which are left stretching across cavities, or from
minute aneurisms in the walls of these cavities.
=
The amount of blood lost varies greatly, from a few drops to a pint
or more. In the largest hæmorrhage ever witnessed by the writer,
over two quarts came up in one day, the patient, in the early cavern-
ous stage, although exceedingly prostrated and anæmic, yet pulling
through and living for several months. The blood may all come at
once, or within a few minutes, or may continue to come at irregular
intervals for hours, days or weeks. After one attack of hæmoptysis,
others are likely to occur from time to time. The natural anxiety
felt by the patient and his friends may be quieted by the assurance
that a hæmorrhage rarely proves fatal, and that, instead of hastening
the progress of the disease, it actually exerts a somewhat favorable in-
fluence on its duration. With hemoptysis, the cough may be no
stronger than usual, or it may come in violent paroxysms, in the latter
case the blood being forced from both nose and mouth. Unless the
blood flows rapidly, it is more or less frothy from admixture of air.
When blood is found issuing from the mouth, it is important at once
to determine its source. If it comes from the lungs, it is preceded by
discomfort in the chest, swells up or is raised by coughing, which is
not, as a rule, violent, and is followed by a sense of relief. It has a
saltish taste, is bright red, and is frothy, unless in great quantity.
After the hæmorrhage has ceased, the patient frequently coughs up
from time to time a little blood, which has a dark-red color from re-
tention in the air-passages. This latter state of things following a hæ-
moptysis, and not a hæmatemesis, forms an important means of dis-
tinguishing between them, when, as often happens during a violent
paroxysm of coughing, the blood from the lungs is swallowed before
it can be expectorated, and then vomited. Auscultation would gen-
erally throw light on the subject, but it is rarely safe to practice this
for several days after the hæmorrhage, for fear of starting it afresh. If
the blood comes from the stomach (hæmatemesis proper), it is pre-
ceded by weight and discomfort in the epigastrium, and sometimes
also by nausea, is expelled generally by one act of vomiting, has a
dark, grumous appearance on account of the gastric juice, unless a good
sized artery has been eaten into (when it is copious and florid), is often
mixed with particles of food in different stages of digestion, and, un-
like blood from the lungs, has an acid odor and reaction. It is fol-
lowed by black-colored discharges from the bowels. When, in epis-
taxis, the blood flowing backwards is coughed up, it can generally be
seen trickling down the pharynx, and will run out the nose, if the
patient leans forward. If it comes from the mouth or fauces, inspec-
tion will usually reveal the fact. If an aneurism has burst into the
air-passages, the blood is bright red, but, from its amount and vio-

DISEASES OF THE RESPIRATORY ORGANS.
245
lence, the patient rarely lives long; and if he does, physical signs,
when it is safe to employ them, will disclose the tumor.
A hæmorrhage can, sometimes, be traced to violent physical exer-
tion, straining at stool, lifting, severe coughing, etc., but oftener no
apparent adequate cause can be remembered. It more easily occurs
in high altitudes with diminished atmospheric pressure. It some-
times, though rarely, seems to be vicarious for menstruation, but cer-
tainly not to the extent which is often imagined.
Pain in the chest, although common, is not an invariable accompa-
niment of phthisis, some patients going through the whole course of
the disease without any; and when it occurs, it does not depend on
any lesion of the pulmonary substance, but generally on a circum-
scribed dry pleurisy, occasioned by an extension of the tubercular
trouble in the direction of the external surface of the lung. These pains
are not usually very severe, and pass off in a few days to return from time
to time. They are particularly apt to be felt in the region of the clavi-
cles or scapula, and occur on both sides successively, often being worse
on the least-affected side; they afford no indication whatever of the
progress of the disease. In view of the fact that post-mortems reveal
so many extensive adhesions of the pleural surfaces after phthisis, it
is remarkable that pain enters so little into its clinical history. Rheu-
matic and neuralgic pains in the chest also frequently occur.
Fever is an invariable accompaniment to phthisis during a part, at
least, of its course, and its intensity increases in proportion to the ra-
pidity of the progress of the disease, although the different forms pre-
sent great variations. No particular fever curve is characteristic of
the malady, and during its course all the chief types of fever are to be
found, the continuous, the remitting, and the intermitting or hectic.
These are rendered very much less regular than might be expected,
from the fact that few cases of phthisis advance with a perfectly uni-
form movement, without remissions, exacerbations, and complica-
tions; hence, there are no definite invariable rules for its temperature
curves. In the worst forms of caseous phthisis the temperature is apt
to be high from the commencement of the disease, and to remain high
to the end, rarely falling below 102° in the morning, unless profuse.
perspirations occur, and rising in the evening to 104° or 105°, and
even now and then to 107°. In average cases it runs from 100° to
102°. In fibroid phthisis the temperature rarely rises above 100°.
The physician may overlook the fever, if his visits are in the forenoon,
for its chief characteristic is its occurrence after noon. Hectic fever
occurs in all the forms of the disease, when softening and excavation
take place, and sometimes, though less frequently, in the earlier stages.
Chills, heat and sweating succeed each other as in regular intermittent
fever, many a time giving occasion for the mistake of confounding the
two diseases, especially in localities where malaria abounds; an error,
246
.
A SYSTEM OF MEDICINE.
however, which ought not to be committed, if physical diagnosis is
properly employed. The chill in hectic is more often only a creeping
chilliness, with cold hands and feet, lasting an hour, or less. It may
be absent. The length of the hot stage is variable. A circumscribed
flush appears on the cheeks, giving them the characteristic bright rosy
tint; the eyes are brilliant, with dilated pupils, the face hot and the
lips dry; the palms of the hands and soles of the feet sometimes burn.
After awhile, perhaps towards morning, follow the night-sweats, which
may be very profuse and exhausting. The sweating does not cor-
respond in amount to the temperature; indeed, it is often profuse,
when there is little fever; depending on loss of power in the vaso-
motor system in the skin, caused by the general exhaustion. It
is often amenable to treatment, and sometimes comes and goes, with-
out any apparent cause. The more active the tuberculization, the
higher the fever. On the other hand, if the process retrogrades, the
thermometer will indicate a fall, so that this instrument will convey a
fair idea of the advance or retrogression of the disease in its various
ups and downs. We have hitherto spoken of temperatures above the
normal. Owing to depression of the constitutional powers, the mer-
cury may fall in the early morning to 92°, or even below, and in some
cases may even remain below the normal during the whole forenoon.
Indeed, it is said to be possible, though far from common, for tuber-
cle to form and go through its stages, without any rise in temperature.
In an average case of phthisis (not incipient) the rise in tempera-
ture begins after 2 P.M., and reaches its maximum, of perhaps 103° or
104°, about 8 P.M. There succeeds a gradual fall until about 5 A.M.,
when, perhaps, 96° may be reached. From this the mercury rises.
until about 10 A.M., when, perhaps, the normal point is reached.
During softening, the maximum may be postponed until 10 or 11 P.M.
The greatest extremes are noticed in active cases in the cavernous
stage, when the curve closely resembles that of suppuration and pyæ-
mia. Diarrhoea, depending on the intestinal tubercular ulceration,
causes a decided evening rise of temperature, followed by well-marked
morning remissions.
The pulse in phthisis is pretty generally accelerated, although it va-
ries with the form of the disease, being lowest and rarely going above
100 in the fibroid variety. Considerable changes may occur in the
lungs with a normal pulse. Still a quickened circulation is the rule,
and it is often found, especially after slight exercise or mental excite-
ment, even before the disease is otherwise recognized. If a normal
pulse is found in the evening, the disease is either making slow pro-
gress, or an arrest has taken place. In the early stage of the disease,
the pulse is apt to be very excitable, going up immediately 15 or 20
beats from very slight causes. As the disease progresses, it corre-
sponds to a considerable extent with the variations in the temperature.
DISEASES OF THE RESPIRATORY ORGANS.
247
The more acute the disease, the more rapid the pulse, from 100 to 140
or more being that of the acutest form. In all forms it is almost
always weak.
The respiration, with its changes, is of more importance to observe
than the pulse. True dyspnoea, or labored respiration, rarely occurs,
unless pneumothorax, cedema, hæmoptysis, pleuritic effusion, or a
copious eruption of miliary tubercles occasion it. Acceleration of the
breathing, however, is an exceedingly common symptom, especially after
any exertion, as going up-stairs, coughing, etc. This depends on the
fever, on the diminution in extent of the breathing surfaces from obstruc-
tion or destruction of the air-vesicles, and on pain. Unless the disease
is very acute, or very far advanced, the respirations are not particularly
rapid, except after exercise.
Digestion and appetite are more or less impaired in the majority
of cases of phthisis, although exceptionally they remain unaffected.
Often, unfortunately, there is utter loss of appetite, and even repug-
nance to food. Vomiting is common, and is frequently caused in a
reflex manner by violent fits of coughing. It may also depend on
subacute gastric catarrh. Phthisical patients, perhaps more than
others, often manifest an antipathy to fatty articles of food.
Diarrhoea of a persistent character may occur at any stage of the
disease, but is more common near its end, when comparatively few
escape it altogether. It may depend on intestinal irritation produced
by undigested food, on atony of the intestines, or on specific tubercu-
lous ulceration of either the small or large bowel. In the latter case,
the diarrhoea is very persistent, or frequently recurs, and is exceedingly
exhausting, weakening the patient more than either the cough, the
fever, or the night-sweats, which is saying a great deal; the discharges.
are soft and ochre-colored, and sometimes streaked with blood, and
accompanying pains and tenderness on pressure are referred to the
seat of ulceration, which is often in Peyer's patches and the solitary
glands. As a result of the tubercular ulceration of the intestines, cir-
cumscribed and even general peritonitis may ensue, with tympanites,
etc. Either perforation of the intestine or hemorrhage from the
bowels may take place. The very profuse discharges near the end of
the disease are often called colliquative diarrhoea. Although this gen-
erally depends on tubercular ulceration, yet it is not necessarily so,
the cause being sometimes imperfect digestion or the watery condition
of the blood.
Emaciation is perhaps the most marked of all the symptoms of
phthisis, and depends upon the fever, the diarrhoea, the perspirations,
the hæmorrhage, the expectoration, poor appetite, imperfect assimila-
tion, etc. Loss of weight is usually noticed from the very beginning,
and in many cases even before any other symptoms have appeared.
Sometimes it thus may be directly the result of the otherwise silently
working tubercle; sometimes it may be non-tubercular, the result of
218
A SYSTEM OF MEDICINE.
impaired digestion and nutrition, enfeebling the vital powers and
establishing, perhaps, the predisposition to the disease, which now has
an opportunity to take root. The total loss of weight produced in the
course of the disease is generally from one-quarter to one-third of the
weight of the individual when healthy, full as much as is lost in any
malady, and involves not the fat alone, but also all the tissues and the
blood. This accounts for the fact that in all ages the disease has been
commonly known simply as consumption, the appropriateness of
which is obvious. In catarrhal phthisis the emaciation is often pro-
gressive and rapid; in the more chronic forms, and especially in the
fibroid variety, it is often very slow, sometimes none taking place for a
long while, and now and then a gain in flesh following. In the latter
cases the progress of the disease may be considered to be either tem-
porarily or permanently arrested. With the emaciation generally go
great debility and loss of muscular power. During the first part of the
disease, this is rarely sufficient to confine the patient to the house, and
even in the last stage he may be up and out of doors to the last day of
life. But generally the few weeks or months at the end have to be
passed in bed. The strength of different patients varies greatly. Some
manage to work during a considerable part of the disease, and others
are practically used up from the start.
Suppression of menstruation, either partial or entire, is a com-
mon symptom, due to the anæmia and exhaustion. Sometimes in young
girls it occurs very early, but oftener it comes on after the disease has
made considerable progress. The patients themselves, in either case, are
frequently persuaded that the diminished amount or suppression of
the menses is the sole cause of their sickness, and beg the physician to
He
give them something to bring it on, and thus accomplish a cure.
should instruct them that this is an effect, and not the cause, of their
troubles, and that nothing but injury can follow the use of violent
emmenagogues.
Hopefulness and buoyancy of spirits are certainly to be classed as
symptoms of phthisis. It is generally very easy to persuade a con-
sumptive, even when reduced to a skeleton, and confined to the bed from
weakness, one whom even a friend, utterly ignorant of medicine, recog-
nizes as rapidly passing away, that he has only a little throat difficulty
or a slight bronchial trouble, from which he will soon recover. Such
a patient, even with one foot in the grave, is constantly making plans
for the future, and telling what he will do next winter or next summer
or next year. He makes light of his bad symptoms, always has some
simple explanation for them, is constantly rejoicing over the slightest
indications of improvement, regarding them as the harbingers of re-
covery. In fact, his hopefulness amounts almost to an insane delusion.
Consumptives without unwarranted hopefulness form a very small
minority.
Hoarseness, occurring in phthisis, may be simply catarrhal, but if
DISEASES OF THE RESPIRATORY ORGANS.
249
not of very short duration, it generally indicates an extension of the
tubercular process to the larynx. Tubercular laryngitis is almost.
always secondary to pulmonary tuberculosis. It may exist early, but
is more common in the later stages. Although sometimes slight, yet
very few patients entirely escape it. Late in the disease, the sufferings
from the laryngeal affection may be so great that the patient's anxiety
seems to be only to get rid of them, the lung symptoms being as
nothing in his eyes. The voice may be entirely lost (aphonia), every
act of deglutition may excite great pain, the pain arising from the
pressure on the larynx (very rarely on the pharynx), of the food when
being swallowed. The patient often dreads to eat in consequence. A
burning pain is often present, even when deglutition is not taking place.
Laryngeal symptoms are always unfavorable.
Clubbed fingers and toes, a bulbous drum-stick-like enlargement of
their terminal phalanges, with claw-like in-curving nails, most common
in cases of long duration, are noticed in about one-quarter of the cases
of phthisis in its later stages. They are not peculiar to this malady,
being also seen frequently in cases of organic heart-disease with marked
cyanosis. This deformity, which occasionally is very striking, proba-
bly depends upon hypertrophy of the connective tissue due to inter-
ference with the peripheral circulation.
Edema of the feet and ankles frequently comes on near the end,
and is always a symptom that augurs ill. It may be due to thrombosis
of the veins of one or both lower extremities, dependent on a weak heart
and a consequent slow return circulation, or much less often on sec-
ondary changes in the kidneys. At first, the swelling is slight and
disappears on assuming the recumbent position, but gradually it in-
creases and extends, perhaps, up to the body and is constant.
Varieties of Phthisis. In the section on pathology and pathologi-
cal anatomy, the two great divisions of phthisis into catarrhal or caseous.
and fibroid have been shown. The symptomatology of the most com-
mon or chronic form of caseous phthisis has already been given; that
of fibroid phthisis will soon follow. It only remains to describe the
course of phthisis florida, which is a very acute form of caseous
phthisis. Different authors have described other varieties, such as
hæmorrhagic phthisis, characterized by frequent and copious hæmor-
rhages without much detectable disease of the lung for a long time, and
five times as common in men as in women; scrofulous phthisis, which
is preceded or accompanied by scrofulous affections of joints, caries of
the sternum, ribs and vertebræ, otorrhoea, fistula in ano, enlarged and
caseating glands, etc.; latent phthisis, and others; but it seems to the
writer an unnecessary refinement, and only perplexing to the student to
increase to too great an extent the varieties of the disease. Acute miliary
tuberculosis can hardly be called a lung disease, although miliary tu-
bercles are deposited in the lungs in common with many other organs.
250
A SYSTEM OF MEDICINE.
Phthisis florida or acute phthisis, sometimes called galloping con-
sumption, is comparatively rare. It runs its course in a few weeks or
months, and rapidly involves almost the whole of one or parts of both
lungs. Its symptoms are chills, high fever, rapid pulse, anorexia,
vomiting, great prostration, a cough, generally violent, and pain in the
chest. The temperature runs up to 104° or 105° F., or higher, with
evening exacerbations and morning remissions. Emaciation, exhaust-
ing sweats, rapid breathing, great dyspnoea, livid prolabia, and occa-
sional diarrhoea are noticeable. The expectoration is trifling or puru-
lent and bloody, but not rusty. Delirium often sets in before death.
In some cases, the cheesy metamorphosis does not take place, but
great quantities of miliary tubercles are crowded into both lungs, and
either remain isolated, or else coalesce. When they remain isolated,
there may be little or no noticeable dulness on percussion, and no other
signs of solidification, which increases the difficulty in diagnosis.
Fibroid phthisis is very much less common than the chronic ca-
tarrhal form, and its course is very much longer, often lasting for many
years. It begins with a slight, persistent cough, either dry, or with
slight mucous expectoration, more troublesome in cold weather, but
better for awhile, and sometimes absent, in summer time, finally, how-
ever, becoming continuous all the year through. The appetite, weight
and strength may remain almost unimpaired for a long time. At
length, the thermometer begins to show 100° F., or higher, in the even-
ing, the pulse is small and weak, chills and sweats occur, appetite and
digestion fail, the weight decreases, the cough grows more violent, and
often ends with vomiting. Expectoration is more profuse and purulent,
and is often very fetid from retention in the bronchial dilatations.
Other late symptoms are hoarseness, diarrhoea, ædema of the feet and
ankles, swelling of the legs and scrotum, and ascites. Hæmoptysis is
a common symptom all through.
Diagnosis.—In daily practice, phthisis has to be discriminated
from a number of diseases, the most important of which are bron-
chitis, pleurisy, croupous pneumonia; pulmonary cancer, pulmonary
syphilis, abscess, and gangrene; anæmia and chlorosis. There is
danger of confusing phthisis florida with acute pneumonia, acute
pleurisy, typhoid fever and capillary bronchitis. It is often desirable
also to distinguish a common phthisical cavity from a bronchial
dilatation, such as is met with in fibroid phthisis.
At the outset, it may be well to call particular attention to the fact,
which cannot be reiterated too often, as it is one of the most essential
points in the diagnosis of phthisis, that the physical signs indicative
of the trouble almost invariably begin at one apex of the lung, and gradu-
ally creep downwards, and that some time before they have reached
the lower portion of the lung, similar signs begin to appear at the
other apex. Thus, although the disease, if very extensive, affects both
DISEASES OF THE RESPIRATORY ORGANS.
251
lungs, yet it is not bilateral in the usual sense of the term, the stage of
the affection in one lung always being behind that of the affection in
the other. The apices, therefore, are always the most important parts
to be examined.
Chronic bronchitis can easily be discriminated from phthisis,
after the latter has lasted sufficiently long for the physical signs of
solidification of lung substance (see chapter on Physical Diagnosis) to
become well marked, by the absence of those signs, by the absence of
severe constitutional symptoms, and also by the fact that it is strictly
a bilateral disease. It is only at an early stage of phthisis, before the
evidences of solidification have become very positive, that any doubt
can reasonably arise; and even here the skilled auscultator is generally
able to detect the nice shades of difference necessary for the diagnosis.
Exceptionally, however, there occur cases, where it is hard to say
whether the slight amount of dulness, broncho-vesicular respiration,
and increased vocal resonance, which may be heard at the right apex,
exceeds that which is allowable at that place in health. It may be of
assistance to remember in such cases, that the general constitutional
disturbance in phthisis, but not in bronchitis, is apt to be quite notice-
able even from the beginning; but, on the other hand, a patient with
bronchitis may be more or less debilitated from other causes. In like
manner, for a while other symptoms, even that of hæmorrhage, may
be capable of a double construction, and unless in such cases the bacilli
tuberculosis can be found in the sputa, the physician should be con-
tent to reserve his judgment until definite signs of consolidation can
be detected, for which, however, he has not generally long to wait.
Chronic pleurisy with effusion causes a persistent cough, emacia-
tion, prostration, dyspnoea, and, if the fluid is pus, regular hectic with
night sweats, all of which symptoms are common to phthisis. One
who has a good practical knowledge of physical diagnosis, however,
need never confound the two diseases. The dulness in pleurisy
begins at the lower part of the chest and gradually creeps upwards,
and is always more pronounced than that of phthisis, generally
amounting to flatness. The others signs over the lower part of the
chest also, the absence or diminution of respiratory sounds, of vocal
resonance and fremitus, etc., unite in proclaiming the collection of
fluid. When this collection is sufficient to solidify by compression the
superjacent lung, it may be in some cases for a time difficult to decide
whether we have a case of pleuritic effusion alone, or of one compli-
cated with phthisis, the signs of solidification at the apex, either from
compression or from tubercular deposit, being pretty much the same.
If, however, as is often the case with the latter trouble, rales also are
present at the apex, if the emaciation and hectic are particularly well
marked, aspiration showing no pus in the pleural cavity and the tem-
perature ranging from 100° to 103°, and if hæmoptysis has occurred,
252
A SYSTEM OF MEDICINE.
we have very strong reasons for suspecting the complication. This willi
be reduced to a certainty if, after a while, a tubercular deposit is found,
by its physical signs, to have taken place at the other apex. If, after
the radical operation for empyema, with daily washing out of the pleu-
ral cavity, the temperature does not fall to nearly the normal, phthisis
in connection may be suspected. If the pleuritic trouble affects both
sides of the chest, a phthisical complication is exceedingly probable.
Pneumonia (acute croupous), in the great majority of cases when
the whole lung is not attacked, affects by preference the lower lobe.
This fact alone generally makes the differential diagnosis easy. Ex-
ceptionally, however, it may involve the apex, the favorite seat of
phthisis, when the physical signs will be the same as those of the latter
disease. The history of the case will then immediately settle the
question, unless, as is possible, the trouble begins as croupous pneu-
monia, and phthisis supervenes on an imperfect resolution. The be-
ginning of phthisis in a lower lobe is exceedingly rare.
Here
Pulmonary cancer is comparatively a very rare disease, but the
possibility of its existence and the danger of its being mistaken for
consumption should not be lost sight of, especially as some of its im-
portant symptoms, cough, hæmoptysis, emaciation, night-sweats, anæ-
mia, and solidified lung substance, are common also to phthisis. When
it is secondary to a cancerous tumor in other parts of the body where it
can be inspected, as in the breast or uterus, its probable detection in the
lungs is rendered easy by the fact that cancer and tubercle rarely co-
exist, and that the lungs are especially apt to be invaded by cancer
after its extirpation in another place. Therefore any grave pulmonary
symptoms and signs under such circumstances point to cancer.
both lungs are apt to be affected; but in primary cancerous infiltration
of the lung, only one side of the chest is invaded. On this hinges a
strong diagnostic point, for if the same amount of deposit were tuber-
cular, we should surely expect to find more at the other apex. Be-
sides, in cancer of the lung the solidified portion does not soften and
break down so quickly and extensively as in phthisis; therefore the
signs of softening, the moist rales, and those of cavities do not show
themselves for a long while after the time of their usual appearance.
in phthisis. As to the symptoms, the currant-jelly expectoration of
cancer is not found in phthisis, nor is the facies of the cancerous
cachexia; fever and high pulse do not come till late in cancer, and
emaciation is more tardy; pain is persistent and severe, while it is en-
tirely absent or transient, stitch-like and shifting in phthisis.
Pulmonary syphilis, also rare, can be distinguished from phthisis
with any degree of certainty only by a previous syphilitic history of
the patient; nor will this always suffice, for syphilis is undoubtedly
one of the causes of the tuberculous predisposition. Hints may be
derived from the fact that syphilitic nodulus affect generally one lung
DISEASES OF THE RESPIRATORY ORGANS.
253
only, generally the base or lower part of the upper lobe, that they do
not spread extensively, and that they are not apt to be accompanied
by hæmoptysis or fever.
Pulmonary abscess, occurring after pneumonia, exhibits the same
physical signs as a phthisical cavity; but it affects only one lung and
usually the lower lobe of that, causes a comparatively small amount
of constitutional disturbance, and emits copious, purulent, fetid sputa.
Pulmonary gangrene may also exhibit the physical signs of ex-
cavation, and produce, like phthisis, cough, emaciation, hæmoptysis,
great prostration, dyspnoea, etc., but the cavity is found at the lower
part of one lung only. The strong diagnostic criterion of pulmonary
gangrene is the really terrible and persistent fetor of the expectoration
and of the breath, especially after coughing, taken in connection with
the signs of breaking down of the pulmonary tissue and its generally
brownish-colored sputum.
Bronchial dilatation of the saccular form gives rise also to the signs
of a cavity, and that of the cylindrical form to bronchial respiration,
yet these are by far more common at the middle or lower portion of
the chest, and are accompanied by less night-sweating, emaciation
and hæmorrhage. The dulness on percussion around the saccular di-
latation is also less than about the more common excavation, and that
over the cylindrical dilatation is not at all proportionate to the amount.
of bronchial or tubular respiration. Bronchial dilatation is more com-
mon in advanced and a common phthisical cavity in early life; in the
former, the physical signs do not change for months, in the latter the
affection is less stationary. In the former the cavernous signs precede
the dulness, in the latter the dulness precedes the cavernous signs.
The expectoration in bronchial dilatation is more abundant and often
very fetid, almost rivalling the odor of gangrene, and the cough is more
persistent.
The diagnosis of phthisis from anæmia and chlorosis is made by the
physical signs.
Acute phthisis, or phthisis florida, when the tubercles are scattered
throughout the lungs, is sometimes distinguished with difficulty from
capillary bronchitis. The physical signs may be much the same in
the latter disease, except that the rales are more noticeable at the lower
part of the chest, but the emaciation, chills and night-sweats are ab-
sent, and the height and variations of temperature are less. When,
however, signs of aggregation of tubercles, evidenced by dulness, are
present, and hæmorrhage, the case becomes clear enough. Acute
phthisis often resembles typhoid fever, but the eruption is wanting,
the temperature has great and sudden variations, instead of being per-
sistently high after it has reached its acme, and the physical signs
steadily progress. Tympanites, iliac tenderness and gurgling are absent,
and generally diarrhoea. Respiration is much more embarrassed than
254
A SYSTEM OF MEDICINE.
in typhoid. Croupous pneumonia and heart disease, having some
symptoms in common, have sometimes been mistaken for acute phthisis.
Diagnostic Value of Bacilli Tuberculosis.-In the vast ma-
jority of cases of phthisis which present themselves to the physician for
examination, the physical signs, in connection with the symptoms, are
amply sufficient for a positive diagnosis. There are cases occasionally,
however, which even the skilled diagnostician recognizes as doubtful.
Many of such cases can be cleared up, and supporting evidence can
be furnished in cases that are not doubtful, by the microscopical ex-
amination of the sputa with reference to the detection of Koch's ba-
cilli tuberculosis. It may be laid down as an axiom, no longer to be
stated on the authority merely of Koch, Ehrlich and Gibbes, but resting
on the testimony of hundreds, and perhaps thousands of observers,
that, with few exceptions, if tubercle bacilli are found in the sputum,
active tubercular disease exists in the lungs, in the larynx, or in both.
On the other hand, if after repeated and careful examinations (at least
four or five, and better more), by one who has made himself familiar
with the necessary processes, no bacilli are found in the sputum, pro-
vided that it comes from the lungs and not from the upper air-passages,
tubercular disease of the lungs probably does not exist; at any rate,
no softening foci are discharging into the bronchi. The bacilli are
present in greatest numbers in acute phthisis, or at the times when
the chronic disease is making the greatest progress. In quiescent cases,
and in a small proportion of cases of fibroid phthisis, they may be-
come greatly diminished, or may even entirely disappear. They may
be found in the fluid of a hæmorrhage from the lungs, or in that of a
perineal fistula associated with lung symptoms, or in discharge from
laryngeal ulcers, where they are highly diagnostic. They are apt to
vary in number according to the period of the day at which the sputum
is expectorated, being more numerous in the morning. They are not
evenly distributed in the sputum. They are never present in em-
physema, bronchitis, nor in any non-tubercular disease of the lungs. Al-
lowance must be made for the fact that in true tuberculosis the sputum
examined may come from the nose, pharynx or mouth, when no bacilli
will be found. Again, as Gibbes states, a lung may be stuffed with tu-
bercles, each one containing thousands of bacilli, and yet the patient.
may die before the destructive process has gone far enough to cause any
of them to be ejected with the sputum. Although incipient phthisis
may sometimes be recognized by bacilli in the sputa before the physi-
cal signs are distinct enough to warrant a positive diagnosis, yet in this
condition the quantity of expectoration is sometimes so trifling, that
it is difficult to assure one's self that what is under examination really
comes from the lungs. On the other hand, it may be wise for us to
remember the theoretical objection to the statement that tubercle ba-
cilli in the sputum mean tuberculosis pulmonum, as expressed in the
DISEASES OF THE RESPIRATORY ORGANS.
255
following question. If, when exposed, we are constantly inhaling, all
of us, these bacilli, why should they not be removed by our expectora-
tion when they fail to take root? Practically, however, we have abun-
dant evidence to support the truth of the above statement in the great
majority of cases, and we cordially welcome to our aid this new and
efficient method of diagnosis.
The two principal methods now used for the detection of the tuber-
cle bacillus are those of Koch-Ehrlich and Gibbes. Numerous modi-
fications of each of these are advocated in different parts of the world.
Some of those which are most easily accessible to American readers
can be found described in the article by Haupt in the Transactions
for 1883 of the American Institute of Homœopathy, in one by Gradle
and Waltmann in the Medical News, for February 17th, 1883 (Phila.),
in one by Berman in the same paper for December 1st, 1883, in one
by Mercer, in the Medical News for July 7th, 1883, page 24, etc., etc.
The following process, which I have generally followed, taken from the
appendix to Flint's Practice of Medicine, is perhaps as convenient as
any. It is called
Ehrlich's Modified Method. "This process may be divided
into three steps: (1) the preparation of the sputum for staining; (2)
the preparation of the staining fluid, the staining of the sputum, and
its preparation for the microscopical examination; (3) the microscopi-
cal recognition of the bacilli."
First Step.-"A small quantity of the suspected sputum is seized.
with a forceps and placed upon the centre of a carefully cleansed cover-
glass. A second clear cover-glass is then firmly pressed upon the first,
until the sputum is equally distributed upon the opposed surfaces of
both glasses. The covers are then separated by gentle lateral trac-
tion, and placed aside, with the sputum upward, until the latter is
almost or quite dry. The covers are passed a few times through the
flame of a Bunsen burner, or of an alcohol lamp, after which the spu-
tum is ready for staining."
Second Step.-"The staining fluid is prepared by mixing the fil-
trate from a mixture of aniline oil with a saturated alcoholic solution
of fuchsine. The aniline oil is first thoroughly shaken in a flask with
pure water, until the latter assumes a milky appearance. It is desir-
able that such a quantity of oil be added to the water, that a few drops
of the oil will appear on the surface when the mixture is allowed to
stand a moment. The mixture is then filtered, and the filtrate, which
is nearly colorless, is placed in a porcelain evaporating dish, or a large
watch-glass."
"A few drops of a saturated alcoholic solution of fuchsine are now
added to the filtrate, the proportion being about ten drops of the
fuchsine solution to one fluidounce of the filtrate. The staining fluid
is then ready for use. The porcelain evaporating dish or watch-glass
256
A SYSTEM OF MEDICINE.
is now placed over a water-bath, and the staining fluid heated until a
little vapor is seen arising from its surface. The cover-glasses are next
gently dropped upon the surface of the staining fluid and allowed to
float, with the side upon which the sputum is spread downward, for
about fifteen minutes, the fluid being kept uniformly at the point of
gentle evaporation, during that time, by regulation of the flame be-
neath the water-bath."
"If it seem desirable, in doubtful cases, to subject the sputum to a
longer action of the staining fluid, the covers may be placed upon the
surface of the fluid and allowed to remain for twenty-four hours in the
cold fluid; at the end of which interval the process of heating should be
adopted as above described and for the same length of time. After
proper exposure of the sputum to the staining fluid, according to
either of the above methods, the covers are removed and the sputum
is seen to be colored red. The covers are then washed an instant in
pure water, to remove any excess of the fluid, and next immersed for
a moment in a watery solution of pure white nitric acid, in the pro-
portion of one to five. Most of the color is abstracted from the sputum
by the nitric acid solution, and all the bacilli, save those of tubercle,
are decolorized. The cover-glass is next quickly dipped into pure
water, to remove any excess of nitric acid, and its surface which has
not the layer of sputum upon it carefully wiped dry with a piece of
soft muslin. A drop of glycerin is now put upon a microscopic slide,
and the cover-glass placed upon this with the sputum downward."
Third Step.-"The bacilli are recognized under the microscope by
the fact that they have retained their red color, while all other bacteria
have been decolorized. The bacillus of leprosy forms the only excep-
tion to the above rule. The diameter of the bacilli is from about one-
quarter to three-quarters that of a red blood-corpuscle. Their form is
not especially distinctive, although many of the rods present a some-
what characteristic angular bend or a crescentic shape. Some of the
bacilli contain globular spores, which are held by some pathologists
to denote that rapid reproduction of the micro-organisms is taking
place."
Sources of Error.-"Small particles of the fuchsine are often pre-
cipitated, and, although usually amorphous, may assume a form re-
sembling that of the bacilli of Koch. The sputum for the entire
twenty-four hours should be examined, as the bacilli are sometimes
absent from sputum collected during a shorter interval, even although
present in the expectoration of the same patient at some other hour of
the day. Since the micro-organisms are often irregularly distributed
in the sputum, repeated examinations should be made before a nega-
tive conclusion relative to their presence is reached."
Generally the most opaque part should be selected. A very neat
device for floating cover-glasses on the staining fluid is a little spoon or
DISEASES OF THE RESPIRATORY ORGANS.
257
loop of bent wire. Some prefer also to stain the background another
color, in order to show the bacilli better by contrast. Thus stained,
the bacilli can be detected with a good one-fifth or one-quarter objec-
tive, with simple central illumination, without a condenser; but they
can be brought out much better by higher powers and special illu-
mination. Fraenzel recommends a one-twelfth immersion objective
and No. 4 eye-piece, with Abbé's illuminating apparatus.
The following method I have not tried, but quote it from the
Lancet, of May 5th, 1883, as coming from quite an authority on the
subject.
"A RAPID METHOD OF DEMONSTRATING THE TUBERCLE BACILLUS WITH-
OUT THE USE OF NITRIC ACID.-Dr. Heneage Gibbes, in a paper on this
subject, says: The following method, which I have used for some time
with great success, will, I think, prove useful to those requiring the de-
monstration of the tubercle bacillus for diagnostic purposes in a rapid
manner. The great advantage consists in doing away with the use of
nitric acid. The stain is made as follows: Take of rosanilin hydro-
chloride two grammes, methyl blue one gramme; rub them up in a
glass mortar. Then dissolve anilin oil 3 c.c. in rectified spirit 15 c.c.;
add the spirit slowly to the stains until all is dissolved, then slowly
add distilled water 15 c.c.; keep in a stoppered bottle. To use the
stain: The sputum having been dried on the cover-glass in the usual.
manner, a few drops. of the stain are poured into a test-tube and
warmed; as soon as steam rises pour into a watch-glass, and place the
cover-glass on the stain. Allow it to remain for four or five minutes,
then wash in methylated spirit until no more color comes away; drain
thoroughly and dry, either in the air or over a spirit-lamp. Mount in
Canada balsam. The whole process, after the sputum is dried, need
not take more than six or seven minutes. This process is also valu-
able for sections of tissue containing bacilli, as they can be doubly
stained without the least trouble. I have not tried to do this against
time, but have merely placed the sections in the stain and allowed
them to remain for some hours, and then transferred them to methy-
lated spirit, where they have been left as long as the color came out.
In this way beautiful specimens have been made, without the shrink-
ing which always occurs in the nitric acid process."
Dr. R. C. Smith has succeeded in demonstrating with facility the
presence of the bacilli in the breath of phthisical patients, by causing
them to breathe through two thin sheets of gun-cotton in a respirator,
and then dissolving the gun-cotton in rectified spirit and ether. The
collodion thus formed is poured over a microscopic slide, and in the
thin film, stained by the usual methods, the bacilli appear (Lancet,
January 20th, 1883). Dr. C. T. Williams suspended glass plates covered
with glycerin in the extracting flues of the Brompton Hospital for
consumptives, through which the air exhaled by the patients passes.
VOL. I.-17
258
A SYSTEM OF MEDICINE.
out at the rate of three hundred feet a minute, and in the glycerin
found the bacilli in great abundance (Lancet, February 24th, 1883).
While examining the sputum for bacilli, the physician should not
forget to look also with the microscope for fragments of the areolar
and elastic tissue from disintegration of the lung substance. Fenwick's
process of preparing it is the best. The sputa is to be mixed with an
equal quantity of a solution of one part of caustic soda in five of dis-
tilled water. After boiling, four times as much water is to be added to
the mixture in a conical glass, and on cooling the elastic tissue will be
found in the sediment. The fibrils are often in circles and half circles
from the form of the air-vesicles, and are sometimes, though rarely,
present before the physical signs of the disease appear. In the late
stages they are abundant; Drs. Detweiler and Meissen having found the
elastic tissue in 82 cases out of 87 examined, the bacilli showing in 85.
FIG. 6.

b
a
Elastic lung tissue (a), and Bacilli tuberculosis (b).
Prognosis. Nobody needs to be told that, as a general thing, the
outlook is bad, and yet the prevailing sentiment among the profession.
to-day is far more encouraging than formerly; partially owing to better
methods of treatment, hygienic, dietetic and medicinal, and partially
because, with the rapid advance in the science of auscultation and per-
cussion, the diagnosis can be accurately made at a much earlier stage
in the disease, when of course all remedial measures are more effec-
tive. The general impression among the laity, whose ideas almost
always lag behind, is still perhaps almost as hopeless as it was among
the profession a comparatively few years ago. As an index of the
feeling among physicians, Dr. John Hughes Bennett says: "At present,
so far from phthisis being considered to be uniformly or even gener-
ally fatal, it is admitted that treatment can in a great majority of cases
prolong life, whilst in many, the number of which is annually in-
creasing, a complete and permanent cure may be effected." Prof.
Austin Flint, and others of long practice, consider that "the mortality
from the disease has undoubtedly diminished within the past three
decades." He reports that out of 670 cases of which he kept records
in thirty-four years, 44 ended in complete recovery, and in 31 the dis-
ease was arrested without perfect recovery ensuing. The followers of
DISEASES OF THE RESPIRATORY ORGANS.
259
Hahnemann can probably show a still better record. Undoubtedly
the science of homoeopathy, by modifying and influencing, directly
and indirectly, old school treatment, has had not a little to do with
the present lessened death rate. When the patient is fortunate enough
to recover, absorption or calcification of the deposit takes place, or the
walls of a cavity may cicatrize. The physical signs of solidification
or of a cavity sometimes remain long after the patient has been re-
stored to perfect health. At one time it was the fashion to doubt the
correctness of the diagnosis when a patient recovered; but since the
institution of the practice of making such immense numbers of care-
ful autopsies in large hospitals, especially in Europe, cicatrices and
calcifications and remnants of old solidifications and innocuous cavi-
ties, bearing ample testimony to the previous existence of tubercular
trouble, have been so frequently and repeatedly found in persons who
have died of some other disease, although many years before they may
have had hæmoptysis or exhibited other phthisical symptoms, that it
is absolutely inconceivable that any rational mind should doubt the
possibility of a perfect cure in any stage of the disease. The modern
methods of diagnosis, including the microscopical detection of the
bacilli, are so accurate, that they may almost be considered as cumu-
lative evidence to such positive demonstrations as these necropsies.
Although admitting the possibility of a cure in the third stage of
phthisis, it is almost unnecessary to state that the vast majority of re-
coveries occur in the early part of the disease.
Looking at the varieties of the affection, acute phthisis, with its per-
sistent, intense fever, rapid emaciation, and formation of cavities, is
almost hopeless, destroying life in a few weeks, and rarely exceeding
six months. Laryngeal phthisis is likewise short and wellnigh hope-
less. In fibroid phthisis, on the other hand, although complete re-
covery rarely occurs, yet life may be prolonged occasionally for twenty
or thirty or more years. The average is perhaps eight or ten years.
In case the fibroid contraction of the lung is very marked, the ob-
structed circulation and consequent dilatation of the heart and kidney
affection may do considerable to hurry the patient off. A second attack
of any form of the disease is much more unfavorable than the first.
Perhaps the most frequent duration of the common form of the disease
among all classes of society is from a year and a half to two years.
This is particularly true of the poorer classes in the community, those
having sufficient means to enable them to enjoy the advantages of good
treatment and the comforts of life generally, often prolonging their
days much beyond this period. Dr. C. T. Williams, of England, who
has compiled statistics on this point, states that the average duration
among the upper classes in 198 cases, where death was the result, was
seven years and eight months, and that the later in life a person was
attacked, the longer did he have a chance of living. Females averaged
two years less than males.
260
A SYSTEM OF MEDICINE.
At the beginning of the ordinary form of the disease, if it seems to
advance slowly, and without much fever and emaciation, under favor-
able circumstances the patient may be encouraged, but the prognosis
should be cautious. In the second and third stages, the favorable
symptoms are a low pulse and temperature, a good appetite and diges-
tion, not much emaciation or expectoration, the slow increase and
limitation of the dulness or cavernous signs to one lung (the less of that
the better), little diarrhoea or sweating, and the capability for taking
exercise. The unfavorable symptoms are high pulse and temperature,
anorexia, indigestion, considerable and progressive emaciation, strong
hereditary predisposition, profuse expectoration, copious and frequent
hæmorrhage, the rapid extension of the local manifestations of the dis-
ease and its occupation of the second lung, perineal fistula, exhausting
diarrhoea and night-sweats, great muscular prostration, and the com-
plications of chronic laryngitis, pleurisy with effusion, capillary
bronchitis, pulmonary edema of the feet and legs, and pneumothorax.
In fact, as death occurs in the great majority of cases by asthenia be-
fore sufficient lung tissue has been destroyed to produce apnoea, any
symptom which causes a special drain on the vitality of the patient is
of bad omen. He is literally worn out. The most important element
in the prognosis is the amount of general infection of the system. In
average cases of phthisis, the nearer this comes to the degree of infec-
tion in acute phthisis, which resembles the pyæmic state, the more
rapid will be the course of the disease. The acute process may be fired
up at any time in the course of a slowly-proceeding phthisis, or com-
plications may arise; and on the other hand, a patient seemingly with
one foot in the grave may yet drag out an existence for a surprisingly
long time. So that it behooves the physician, although he may be very
confident of his diagnosis, and in other respects fairly so of his prog-
nosis, to be exceedingly cautious about setting the exact time of death.
Hæmoptysis, if very profuse in the later stages, may cause death by
suffocation, but this event is not very common. If profuse and fre-
quent, it may hasten death by producing exhaustion; but if not, sta-
tistics seem to show that it has a favorable effect on the prognosis;
that such patients live longer than those who do not bleed, and that
they more often recover.
"
The bacilli tuberculosis under the microscope influence the prog-
nosis, as follows: If found in abundance on frequently repeated ex-
aminations, the disease, as a rule (with numerous exceptions), may be
considered as actively progressing, and vice versa, if they are few in
number. If, after having been present for some time in a case of
phthisis, they entirely disappear, and their absence continues on re-
peated examination, the indications are that the tubercular disease has
ended, no matter how much damage to the lung tissue remains.
Treatment. The absolutely indisputable fact that many (albeit
DISEASES OF THE RESPIRATORY ORGANS.
261
still a small minority) of the victims of phthisis in all stages, particu-
larly the first, are restored to health, and that even among those who
die the great majority can be more or less benefited by treatment, and
the opinion to-day of a large number of physicians of forty or fifty
years' experience that the mortality of the disease is much less than it
was in the early years of their practice, ought to remove from us the
last vestige of that utter discouragement and hopelessness in under-
taking a case, which used to be far too common, and which necessarily
either leads to inaction, a folding of the hands and a grim contempla-
tion of approaching death, or at least paralyzes our best efforts. It is
not necessary to add, and likewise destroys the helpful confidence of
the patient, for that by a peculiarity of the disease is, as a rule, abun-
dantly assured. This view does not by any means advocate that over-
sanguine enthusiasm which would always promise a cure, for it must be
allowed that, even at the best, the great majority of phthisical patients,
no matter how soon they are seen by the physician, will surely die.
Assuming (as the great majority of scientific men now do) that the
modern doctrine is correct that the bacillus tuberculosis is the cause
of the disease, but that it will act only on a constitution especially pre-
disposed, not only in originating the disease, but also in keeping up its
activity, the rational method would seem to be the avoidance of the
bacillus, its destruction both before and after its entrance into the body
of the patient, and the employment of any means which, in general
terms, will prevent or remove the particular fitness of soil for the growth
of the micro-organism, which fitness we for convenience call the pre-
disposition. These principles will apply, to a great extent, in the
treatment both of the diseased person and of the candidate for the dis-
ease, the latter judged to be such from his family history, or from indi-
cations perceptible or supposed. It sometimes being very difficult to
decide who is and who is not a candidate for the disease, the error, if
any, should be on the safe side.
The destruction at will of tubercle bacilli after their entrance into
the lungs or other organs of the living body, without the simultaneous
destruction of the patient, in spite of many experiments, has never, in
all probability, as yet been accomplished. The natural inference at
first from Koch's great discovery was, especially to an enthusiastic
nature, that some substance might be discovered, some parasiticide,
which, either by inhalation or by introduction in some way into the
blood, might kill the little causes of such great mischief. Whether
any such substance ever will be found or not, it is now impossible to
predict; but even if it is found, there will still be the same need for
treatment for the other equally important factor in the disease, the
diathesis, the susceptibility, the predisposition, the cachexia; for with-
out the removal of this, a new cargo of bacilli, so easy to obtain, will
soon place the patient where he was before. Thus we see that, contrary
262
A SYSTEM OF MEDICINE.
to the expectation of many, the discovery of the bacillus has shed very
little light on the treatment of phthisis (except prophylactic to some
extent), although in ætiology, pathology, diagnosis, and prognosis its
influence has been so sensibly felt. Now, as heretofore, for the most
part, the prevention of the disease in those already predisposed, the
remedy against the acquisition of the diathesis in those not predis-
posed, and the treatment of those in whom the disease has already
started and has made more or less progress, depend on strengthening
and invigorating the system by every available means in the broad
field of hygiene, by climatic influences, and by such medicines as may
in each case seem indicated. The treatment, therefore, will be dis-
cussed as prophylactic, hygienic, climatic, and medicinal.
Prophylactic Treatment.-As to the avoidance of the bacilli,
it has been shown, in the section on ætiology, that in most parts of
the globe it is extremely difficult, if not absolutely impossible, to escape
from their introduction into the system. Still, as the likelihood of
contagion increases with closeness of contact and long continuance of
the exposure, it is not advisable for a healthy person to sleep in the
same bed, and, if possible, not in the same room, with a consumptive.
Nor should he unnecessarily live in sanitaria or other resorts frequented
by consumptives. Those who are obliged to live much with such
persons, should see to it that the ventilation is of the best, and that
the patient's sputum is disinfected, etc., and that they themselves
maintain as much constitutional vigor as possible.
The destruction of the bacillus outside of the body has been the object of
many recent experiments, notably of Drs. Schull and Fischer in Ger-
many,
of MM. Parrot and Martin of France, and others (Med. News,
Phila., Dec. 22d, 1883, and April 19th, 1884), and seems to be satisfac-
torily accomplished. Alcohol, Creosote, Arsenious acid, Corrosive sub-
limate, Thymol, Bromine, Iodine, Iodide and Bromide of potassium,
Salicylic acid, Turpentine, Ammonia, caustic Soda and Potash, Aniline
oil and other substances, were tried and abandoned, because they were
The ver-
either inefficacious or unsatisfactory for some other reason.
dict was in favor of Carbolic acid. With a five per cent. solution of
this placed in a spit-cup, an equal bulk of fresh sputum can be disin-
fected. Every consumptive therefore ought, by good right, as a pre-
cautionary measure, in order to prevent, as far as may be, the trans-
mission of the disease, to spit into such a solution. (Perhaps Platt's
Chlorides or Bromo-chloralum, which lack the villainous smell of
Carbolic acid, would do as well.) The desirability of this can be argued
from the fact that Schull and Fischer found that dried, non-disinfected
sputum, from 95 to 126 days old, was in all instances capable of pro-
ducing tuberculosis in guinea-pigs inoculated with it, and that even
after this age it was active, but that its activity progressively dimin-
ished. They also found that the scalding and boiling of our clothes,
DISEASES OF THE RESPIRATORY ORGANS.
263
in the ordinary process of washing, is sufficient to destroy the virulence
of tubercle bacilli. A committee of the hygienic section of the Vienna
College of Physicians has recently recommended (May 10th, 1884)
boiling the clothing for an hour in water containing Sodium carbonate,
and exposing such as cannot be boiled to a dry or steam heat of 212°
F. for the same time. This committee also advises the disinfection
and prompt removal of the fecal discharges of those who have intestinal
tuberculosis, as well as the disinfection with Carbolic acid and frequent
removal of sputum, not only in sick rooms but also in all public places
where consumptives most congregate, to prevent pulverization, and the
most scrupulous cleanliness of body and bedclothing, floor and walls,
houses and streets. In fact this society, like the great majority of physi-
cians to-day throughout the civilized world, sanctions all those reasonable
expedients which are the natural outgrowth of the bacillus doctrine.
The old proverb about prevention being better than cure being no-
where more applicable than with regard to phthisis, it will, of course,
be understood that prophylactic treatment, other than the avoidance
and destruction of the bacilli, should be undertaken at any time from
the earliest infancy even, in those whom we may have the faintest ex-
cuse for suspecting to have an inherited tendency to the disease, or an
acquired diathesis. This treatment should be mostly hygienic (suita-
ble medicines, of course, being added when necessary), and should be
regulated by the general principles of hygiene, more particularly those
shortly to be mentioned as suitable for persons who have already ac-
quired the disease. In addition, it may be stated that phthisical or
feeble mothers should never be allowed to nurse their own children,
a healthy wet nurse or good boiled milk from a healthy non-tubercu-
lous cow being selected. School life should be carefully regulated,
enjoyable exercise in the open air encouraged, later suitable business
and occupations chosen, involving considerable out-door exercise,
rather than a sedentary life. A phthisical person should not be mar-
ried, both on account of the partner and of the offspring, the best pre-
cepts should be inculcated with regard to diet, temperance, clothing,
ventilation, sleep, etc.,-in fact every agency which can operate to build
up a healthy manhood or womanhood should be systematically em-
ployed for years. Such unremitting care is very often rewarded by an
exemption from the disease, which, aided by carelessness, would, in
all probability, gain a firm foothold.
Hygienic Treatment relates particularly to diet, clothing, fresh air,
exercise, bathing, etc. The great indication in this disease being to
strengthen and invigorate the system, the diet should be of the most
generous kind and should be limited only by the powers of digestion.
Lucky is that phthisical patient who is hungry and knows not that he
has a stomach. Such a one should be encouraged to eat everything
reasonable which he has a relish for, as a well person would eat, the
264
A SYSTEM OF MEDICINE.
more nutritious articles being especially emphasized. Unfortunately
for the majority, however, anorexia and indigestion are too common,
and oppose one of the greatest obstacles to our success. In such cases
the appetite should be tempted, as much as possible, with delicacies.
and favorite articles of food, even if they be not such as we should be
apt to prescribe on theoretical principles; for it is better for the patient
occasionally to eat food not generally considered desirable, and which
may cause a little indigestion, than to eat nothing. No general cast-
iron rule can be laid down for all cases. The homœopathist, who is
accustomed so much to individualize his cases with regard to medi-
cines, must not forget to individualize with regard to diet. Each case.
demands a special study, which should try to ascertain, both from ex-
perience and by experiment, what for that particular case is most di-
gestible and most nourishing. The largest possible latitude should be
allowed, for variety is very desirable. Some with weak stomachs will
digest much more, if they eat less at a time, and four, five or six times
a day. Without particularizing further, it is important to state that
by far the most generally useful article of food for consumptives is
milk, which they should be encouraged to take to the extent of from
one to four pints a day, and which in one form or another will be
found very apt to agree, even if the patient declares at the outset that
he never can take it. If not taken in its simplest form, it can be made
into blanc mange with sea-moss-farine or corn-starch, or cooked with
various farinaceous puddings, or in bread, in oyster-stew, in ice-cream,
etc. Many like it in the form of koumiss, which is now nicely pre-
pared and sold in many of the stores. Cream is a very valuable ad-
junct, and is often used as a substitute for cod-liver oil, its delicious
taste being a great recommendation. Butter and other fats should be
used as far as they can be digested. When the consumptive is very
much prostrated from excessive hæmorrhage or otherwise, Murdock's
Liquid Food forms an admirable restorer, being very easily digested
and nutritious. The occasional occurrence of a bad bottle, resulting
from some imperfection in its preparation, should not militate against
its use any more than one bad egg in a dozen should prevent the use of
the eleven. Cod-liver oil, during the last forty years, has been advocated
extensively throughout the world, and has had a pretty thorough trial.
There is probably nothing specific in its effect on the disease, and its
reputation should rest solely on its nourishing properties. Fat of some
kind seems to be demanded, and the oil, in many cases, answers the
purpose better than any other form. A great objection to it is its
disagreeable taste, which in many excites so much repulsion, that it
should not with them be urged. A less amount of dislike is often
overcome after a while. Wherever it occasions indigestion, diarrhœa,
nausea, anorexia, it should be stopped at once. Four minims of ether
to each teaspoonful will make it digest more easily. If well borne,
DISEASES OF THE RESPIRATORY ORGANS.
265
it may be continued in doses of one, two, or three teaspoonfuls of the
clear, pale oil each meal. Some who cannot take the pure oil can take
an emulsion. Of the numerous emulsions now sold, Phillips's has
given me the most satisfaction. The excessive enthusiasm about cod-
liver oil, so prevalent not long ago, has since been considerably modi-
fied. In most cases, plenty of pure fresh cream or rich milk is to be
preferred. A malt extract is occasionally quite a serviceable food.
One of the best of these is Liebe's; another is Maltine. The same can
be said of the Syrup of the Hypophosphites, which sometimes proves
very beneficial. Alcohol in different forms has been extolled to the
skies, and a few years ago every patient was deluged with whiskey.
Though still recommended by some, its use has greatly declined.
It will undoubtedly often confer temporary benefits and encourage.
the patient; but I have become convinced from careful comparisons
in several hundreds of cases, in some of which it was used in different
forms, and in others abstained from, that in the long run its habitual
use is injurious, and that it is neither a prophylactic nor a curative.
I have had frequent occasion to remonstrate with dispensary patients.
for depriving themselves of milk for the sake of buying ale or beer,
under the impression that it was more strengthening. Not that
alcohol is never useful, but it, like other poisons, should be transferred
from the list of foods to that of medicines, and employed only in the
emergencies where it is strictly called for, which emergencies will be
found seldom to occur.
The clothing should be so regulated that at all times the patient shall
be, in one word, comfortable, or as near so as may be. This covers
the whole ground. Practically, most patients will need woollen or
merino or silk underclothing, being good non-conductors of heat and
absorbers of perspiration, with a chamois-skin vest added in winter
time, and such other garments as will keep them warm. The numer-
ous layers of flannels which the physician, desirous of making an
examination, often sees peeled off, one after another, even in warm
weather, cause excessive perspiration and weakness. At the same
time, the patient should not allow himself to be chilled.
Fresh air is of vital importance to the consumptive. The time has
entirely gone by when such patients were confined to the room, with
cotton-batting stuffed into the window cracks and every breath of pure
outside atmosphere excluded. In these days of what may almost be
called without disrespect the ventilation-craze, to which the public
has got pretty well waked up, it is unnecessary to dwell on this point,
except to suggest that the greatest amount of fresh air possible should
invariably be introduced into the patient's room, day and night, con-
sistent with a proper degree of warmth and the absence of direct
draughts blowing on him. An open fire in a sleeping room is a
luxury which those should have who can afford it. This or a par-
266
A SYSTEM OF MEDICINE.
tially-open furnace register will allow of a window let down at the top
in all but the very coldest weather, or at any rate an open window
in an adjoining room. He should also be encouraged, when strong
enough, to get out-doors into the fresh air every day, unless the weather
is excessively inclement. Ordinary storms he should not mind.
Bodily exercise, particularly out of doors, is now universally recom-
mended as much as the patient's strength will allow; and justly, on
account of the many recoveries which are reported from all over the
world as occurring in consequence of this as a chief factor. It will
necessarily have to be proportioned in amount to the stage of the dis-
ease. Walking and horseback and carriage riding are allowable at all
times when they can be borne. Slowly climbing up a hill is bene-
ficial, and in the early stages carefully conducted gymnastic exercises,
which expand the chest, especially the upper portion, and thus call
for deep inspirations. The health-lift for ten minutes a day may be
tried under instruction. Exercise should not be too violent or per-
sisted in to the extent of exhaustion, and it should be entirely discon-
tinued for a while after a hæmorrhage which is at all severe. The
more mental enjoyment to be derived from the exercise, the more good
it will do; and, therefore, such sports as boating, fishing, hunting, and
also pleasant sight-seeing, for those who like them, are to be desired.
A constitutional walk is a notoriously stupid affair, and yet it is better
than nothing for those who can do no more. Where it is practicable,
benefit often follows a change of occupation from a sedentary life to a
more active one. Undoubtedly, much of the good effects usually
attributed to change of climate may often come from just such a
change of occupation. Patients who are strong enough should be
encouraged to exercise out-doors, properly clad, in all weathers but
the very worst. Those who are at all feeble should be directed to take
their exercise on the instalment plan, frequent rests intervening.
Much more is thus accomplished and with less fatigue. Where the
patient can do no better, sailing should be advised, or swinging in a
hammock, or sitting in a garden, or by an open window, anything, in
fact, to get him into the open air. In the last stages, or in fact at any
time when the disinclination to exertion cannot be overcome, rubbings
and other passive exercises may be employed.
Bathing should be practiced, both for its tonic effect and in order to
encourage the sensible and insensible perspiration, by keeping freely
open the pores of the skin, which has such an intimate relation to the
lungs. This, like out-door life, constitutes a sort of toughening pro-
cess, which diminishes the sensibility of the skin to changes of tem-
perature, and to some extent prevents taking cold. The temperature
and duration of the bath should vary with the reactive power of the
patient, who should never feel chilly for any great length of time after
it, but instead experience a healthy glow. Generally the sponge bath
DISEASES OF THE RESPIRATORY ORGANS.
267
is to be preferred, and in many cases simply sponging the face, neck,
and chest is all that is desirable, on account of feeble reactive power.
If the patient is unused to cold bathing, he may begin, especially in
cold seasons, with tepid water and gradually lower the temperature.
If he has troublesome night-sweats, the warm bath in a bath-tub, from
95° to 96° F., for fifteen or twenty minutes, every other night at bed-
time, the temperature being maintained by the addition from time to
time of hot water, will often prove very serviceable. Salt can be added
with great advantage. Besides diminishing the sweats, other symp-
toms may be benefited-the fever, pulse, cough, expectoration, cold
hands and feet, poor sleep and diarrhoea. If the bath-tub is not
used, the patient should be sponged all over every night until the
relief comes, with hot salt water of a higher temperature. After the
bath the patient should be well rubbed down.
Climatic Treatment, undoubtedly potent, is a much-talked-of
method, one by no means as yet thoroughly understood, and one, the
virtues of which by many people are probably overestimated. Flint, in
his able work on Phthisis, says: "My studies seem to lead to conclusions
at variance with the prevailing popular and professional belief in a
special climate influence. In the first place, it does not appear from
the analysis of my cases that changes of climate have in a marked
degree a beneficial influence, as compared with the hygienic measures
available at home. In the second place, the improvement following
a change appears to pertain alike to different climates and places.
Hence it seems a fair inference that the benefit derived from the
change is due, not so much to a climatic influence per se, as to the cir-
cumstances incidental to the change. These circumstances are often
a change of habits from those which are sedentary and confining
within doors to those involving out-of-door life and activity, freedom
from cares, anxiety, and annoyance of business at home, and, it may
be added, the moral effect of the hope or expectation of being benefited
by climatic influence."
Lebert, in his recent French work on phthisis, thinks that the best
climates do not have any direct or specific action upon tubercular dis-
ease, but that the good they do results from general hygienic influ-
ences. Parkes, the great hygienist, in his well-known work, calls at-
tention to the fact that, in the true Alpine region, where strangers are
so often cured or relieved, and where the male natives, living mostly
out of doors, are almost exempt, the women, who in making em-
broidery, are confined in ill-ventilated rooms all day, and have poor
food, suffer from scrofula or phthisis. He adds: "It would seem even
probable that after all it is not indeed elevation and rarefaction of air,
but simply plenty of fresh air and exercise which cures phthisis."
Climatology as a science is still in its infancy, which fact no one
can appreciate better than he who takes the trouble to wade through
268
A SYSTEM OF MEDICINE.
$
the many and voluminous pages of the intensely (pseudo?) scientific
disquisitions on the subject, which learnedly discuss the influence of
temperature, its range and changes, of dryness or moisture, of winds,
of the weight of the air and barometrical changes, of the electrical
conditions, ozone, the purity of the atmosphere, of the amount of light,
especially of sunshine, of the character of the soil, of the proximity of
the sea, lakes, ponds, rivers, marshes, of the balsamic odors of pine.
forests, and of high altitudes. It cannot be denied that these are of
importance, and that at some future day succeeding generations may
utilize them scientifically; but candor compels us to own that as yet.
we know too little of most of these agencies to warrant an accurate
prescription in individual cases. We cannot claim to have yet got
very far beyond the advice of old Dr. Chambers: "In choosing a home
for your consumptive patient, do not mind the average height of the
thermometer, or its variation; do not trouble yourself about the mean
rainfall; do not be scientific at all; but find out from somebody's
journal how many days were fine enough to go out forenoon and
afternoon; that is the test you require, and by that you may be con-
fidently guided."
The question which is very apt to be asked about a change of cli-
mate is often a very troublesome one to the physician who is consci-
entious and wants to do the best he can by the patient in every way.
Especially is this so among people of moderate circumstances, to whom
the expense is a great burden, depriving the family of many comforts;
and it is often so, even among the wealthy, for various reasons. Never-
theless, it becomes easy enough to decide, if the patient has acute.
phthisis or is in the last stage of the chronic disease, when he will do
far better to remain at home. To send such patients, who look to us
trustingly for advice, and whose hopes of recovery we may feel toler-
ably sure are fallacious, to any place away from family, friends, and
home comforts, or even to allow them to go if we can help it, is not
only exceedingly unwise, but should be condemned in the strongest
language possible. The feeble chance offered by a climate which may
be superior is greatly overbalanced by the almost necessary depression
resulting from the forced separation from dear ones and the absence of
many accustomed luxuries, by the fatigue and dangers of travelling,
and by the far from pleasant prospect of dying in a strange land.
It is only in the first stage, as a rule, that we can dare to hope for
much benefit from a decided change of climate, although sometimes a
patient with a chronic single cavity in one lung and no trouble in the
other, with no special fever, hæmorrhage, or complication, will do well
in a dry, bracing climate. Dr. Pollock's advice is pretty sensible, that
persons ought not to travel at all with feverish symptoms, especially
with high evening temperature; with secondary complications, like
continuous or frequent diarrhoea, serious gastric disorder, or laryngeal
DISEASES OF THE RESPIRATORY ORGANS.
269
irritation; with a large amount of local disease in any stage; with
both lungs diseased; or in such a state of weakness or emaciation as
to require home comforts, peculiar beds or chairs, or varieties of invalid
cookery.
After the physician has decided to recommend his patient to try a
change of climate, or if the patient, taking it into his own hands, in-
forms the physician that he has decided to change, and asks for farther
advice, the question next arises, what climate is best? Dr. Loomis, of
New York, has answered this question very neatly in general terms.
"The individual peculiarities of each case must decide this question.
Experience shows that one individual improves in a warm, moist air;
another individual improves in a cold, dry air. Every phthisical pa-
tient has a climate adapted to his peculiar diathesis; a few well-
directed questions will enable you to determine in which direction
and in what locality your patient will be most likely to receive benefit.
In the first place, by careful questioning determine whether your pa-
tient, when in a state of health, was most vigorous in warm or cold
weather, in a damp or dry atmosphere. Again, you must determine
whether he has most vigor in a dry and cold or a dry and warm atmos-
phere, or in a warm-moist or cold-moist atmosphere. If these ques-
tions cannot be settled by the experience of the patient, direct him to
travel in the direction which seems best suited to his case, until he
finds a locality where he is comparatively comfortable, endeavoring to
select a climate where he may be out of doors every day and at any
hour of the day."
Besides the mere selection of a locality from the point of view of its
temperature, dryness, etc., the physician has several other things to
consider which may be full as important for the patient's recovery.
If he should banish the latter to a place lacking everything like the
food, accommodations, mental resources, and amusements to which he
has been accustomed, no matter how delightful the climate, these
deprivations, with some persons, might more than counterbalance its
good effects. Others, however, might enjoy these changes. Therefore
the individual's tastes should be consulted as far as possible. The
great trouble with our best climates for consumptives in this country
is that to-day they have very little else to recommend them, because
they are so uncivilized, so to speak. Out-of-door life being so neces-
sary, there should be some inducement for it. Has the proposed place.
any such? The constant change of scene and mental occupation in
travelling in foreign countries or in different parts of our own country
without regard to particular climatic indications, especially if it also
brings relief from home cares, anxieties, and business, will sometimes
be of great benefit to a consumptive. For a different class, who have
more resources within themselves and are therefore not so dependent
on outside influences, a long sea voyage in warm latitudes may be the
270
A SYSTEM OF MEDICINE.
best thing, especially if the patient does not suffer excessively from
sea-sickness.
It is particularly important to remember that change of climate is a
relative term, and that to receive benefit from it there is by no means
always the necessity for travelling to the ends of the earth or to a
great distance. Often only a few miles, or possibly a few rods, from a
valley to a hillside, from a swampy neighborhood to a dry, gravelly
soil, may be sufficient. This fact is too often forgotten, but has been
repeatedly proved. In this connection it may be well to state that
the researches of Dr. Bowditch, of Boston, and of Dr. Buchanan, of
England, proving an undoubted connection between dampness of soil
and the prevalence of the disease, and a comparative immunity from
it on high, gravelly soil, well drained, have been abundantly substan-
tiated by the experience of many others. Therefore this element
should be a conspicuous one in the selection of any climate for con-
sumptives. In some cases it may be advisable to recommend a per-
manent residence in the locality where the patient may seem to be
particularly benefited. As a rule, it will be found that more are helped
in a moderately cool and dry air than in a warm, especially if moist,
atmosphere.
As to the choice between the mountains and the seashore, Professor
Loomis thinks that sea air is best for phthisical persons past middle
life, for those who cannot tolerate any sudden change in the atmos-
phere, and for those in whom the tissue-change requires hastening or
stimulating, the system being in too feeble a condition for muscular
exercise. If there seems to be no special need for this hastening,
they are better in the mountains. Consumptives should not go to the
mountains, he thinks, unless they are capable of considerable muscu-
lar activity. Comparative youth and vigor are required. An ex-
hausted nervous system, with an overtaxed brain, the muscle being
in fair condition, will do well at the mountains.
As to the desirability of particular localities, there is space here for
only a few words. For further information the reader is referred to
J. W. Howe's Winter Homes for Invalids (New York), for American
health resorts; to C. Theodore Williams's Influence of Climate on Con-
sumption (London), for foreign climes; and to Walton's Comparison of
the European and American Climatic Resorts (Philadelphia, 1877), for
both. There are other sources of information, but these are perhaps
as accessible and concise as any. No mention will be made here of
foreign resorts, as our own country probably offers more advantageous
regions in far greater variety, and as comparatively few of our people
care to go abroad for the purpose.
Our Southern States have been greatly resorted to in times past,
especially Florida, and doubtless some have been benefited, but the
vast majority of those who have gone to Florida have either died there
DISEASES OF THE RESPIRATORY ORGANS.
271
or have rapidly failed after, perhaps, some improvement at first, and
have come home just in time to die. Those cases which improve
most in Florida are not phthisis, but obstinate bronchitis or slowly-
dragging and imperfectly-resolved pneumonias threatening phthisis,
which often there do remarkably well. The lowlands of the South
are too hot and moist to suit most consumptives, who are very apt to
sink under their depressing and debilitating influence. The malaria
which may poison the system there is another objection. Florida is
one great stretch of lowland, with scarcely any elevation worthy the
name of a hill, except perhaps near its upper borders. While Northern
consumptives rush to these lowlands for help, the natives with the
disease seek the highlands in different directions. Still, it is not to be
denied that some cases of phthisis are benefited here. Magnolia,
Jacksonville, Pilatka, St. Augustine, Enterprise, and Gainesville are
the most frequented resorts in this State.
In the same connection may be mentioned the climate of the Ber-
muda Islands, 700 miles from New York and 600 from Cape Hatteras,
where the climate is very mild and moist, the winter mean temperature
being 60° F., rarely falling below 40°. Cold, southwest, disagreeable
storms are common, however, but malaria is unknown. The winter
in the Bahama Islands, east and southeast of Florida, is warm and
moist. From November to April the temperature varies between 60°
and 70° F., and is equable indeed. The sea breezes from the north are
cool and delightful. In the summer the mercury ranges from 70° to 90°.
Nassau, the capital, is on a range of hills near the coast of the island
of New Providence. Turk's Island at the southern end of the group is
also frequented as a health resort. In the Lesser Antilles, nearer the
equator, are three islands to which consumptives go; Santa Cruz, St.
Thomas and St. Vincent. Santa Cruz has a pleasant and highly cul-
tivated area of 100 square miles of plains and hills, with comfortable
homes, beautiful hard roads and no malaria. The atmosphere is dry,
warm and pure, and the mercury ranges in winter from 76° to 82°,
the summer heat being a little higher. Cuba in winter is of course re-
sorted to, but the climate is warm, moist and inferior. Matanzas, San
Antonio, Santiago and villages in the interior near the mountains have
the best reputation for invalids in this island.
To go to the other extreme, Minnesota has a remarkably cold and dry
climate. Its country is elevated a thousand feet or more, the annual
rainfall is only twenty-five inches, including snow (about forty in Mas-
sachusetts), and the winters are cold and long, although the summers
are hot. The air is dry and bracing, changes of temperature are sud-
den, and forests of spruce and pine abound. It is stated that about
one consumptive in fifteen is cured in Minnesota. Some years ago
very enthusiastic reports were sent from here of wonderful cures, but
we hear much less of such cures now. It is beneficial for those who
272
A SYSTEM OF MEDICINE.
are strong enough to exercise in the open air regularly, and it requires
no little toughness to do this with the thermometer below zero, but
others with less vitality have died by the hundreds. The same re-
marks are applicable to Canada and the famous Adirondack region in
New York, about which so much enthusiasm has been aroused lately,
and so many brilliant hopes have been raised, most of them destined
to disappointment. And yet there certainly have been recoveries in
both of these regions, and also in the White Mountains of New Hamp-
shire.
The Rocky Mountains in Colorado, Wyoming, New Mexico and
Arizona, with their foot-hills and elevated plateau, and with all varie-
ties of temperature, have gained a great reputation for consumptives.
In some parts of Colorado the cold is severe and changes great, but in
others it is very mild and peculiarly dry. The atmosphere is wonder-
fully dry, exhilarating and healthful. The annual rainfall is about
sixteen inches. The average height of the Rocky Mountains is 11,000
feet, some peaks being higher. The celebrated and large North, Middle,
and South Peaks and San Luis, Estes and Manitou Peaks are from
7000 to 9000 feet high. Even at the foot of the mountains the alti-
tude is 4000 feet, and the eastern third of Colorado and western half
of Kansas form one large plateau, gradually rising from 1500 to 4000
feet. A very good feature in Colorado is abundant sunshine, some one
once reporting from a well-favored location 303 clear days in a year.
Bad features are the violent and fierce winds with clouds of dust,
scarcity of water, poor food, and lack of many comforts, except in
Denver and a few other places where the climate is not so favorable.
Besides the places already mentioned, Colorado Springs, Boulder,
Manitou, Pueblo, Cañon City, and Puncha Springs are resorted to by
invalids.
New Mexico and Arizona promise well in the future, when they are
more developed. Tyndale thinks that this country, and particularly
the Mesilla Valley in southern New Mexico, will be the ideal of a warm,
dry climate, when it gets more civilized, on account of its almost
perpetual sunshine, the dryness and purity of the air, so extreme
that meat becomes desiccated, without decomposition, by exposure to
it (dead bodies being formerly brought here for mummification), its
abundant and fine vegetables and fruit, especially grapes, its elevation,
etc. There are now two hotels, which are said to be good, at Las Vegas
Hot Springs, on a branch of the Atchison, Topeka and Sante Fé R. R.
The neighboring State of Texas, in some parts, offers certain ad-
vantages, incident to a dry and warm climate.
The climate of California cannot be described in a word, because
almost every variety is represented in its different parts. Within a
day's ride can be experienced arctic cold, tropical warmth, or great
variableness. The principal health resorts are in Southern California,
DISEASES OF THE RESPIRATORY ORGANS.
273
where many consider the climate to be superior to any in Europe or
America for consumptives, who can be out in the mild and equable
yet somewhat bracing air the most of the time. Many cures have been
reported, and yet many die here too. Eastern consumptives might
expect to derive much more benefit, if it were not for the long and fa-
tiguing journey requisite to get there. Among the most desirable lo-
calities is Santa Barbara, near Point Concepcion, whose climate is dry
and mild and free from changes. In summer the average temperature.
is below 70°, rarely getting above 80°, and in winter the average is 53°.
The coldest day in nine years was 42°. The rainfall is from twelve to
fifteen inches. On the north it is protected from the cold and winds
by the Coast Mountains, and on the south from the sea fogs by beauti-
ful islands. San Diego lies on a bay on the Pacific, 500 miles south of
San Francisco and 150 miles south of Santa Barbara. It is a little
warmer than the latter place, and is subject to sudden changes. The
rainfall is ten inches. Malaria and rheumatism abound here, but not
in San Bernardino, 75 miles from the sea, where the air is warm, dry,
and pleasant. San José, in the beautiful Santa Clara Valley, 50 miles
from San Francisco, and many other places, are resorted to by invalids.
The State Board of Health of California, after a careful consideration,
has favorably reported on two localities for the establishment of a
sanitarium for consumptives-one in the Sierra Madre Valley in Los
Angeles County in almost the extreme southern part of the State, and
the other on Atlas Peak in Napa County, just north of San Francisco,
and at an elevation of 1500 feet.
Aiken, in South Carolina, is much oftener frequented by Eastern in-
valids, being so much nearer. It is on a high, sandy ridge, near the
Savannah River, and has a clear and mild atmosphere, with an even,
warm temperature, except that, sometimes, cold northeast storms pre-
vail. Near by are groves of pines. Spartanburg and Greenville are
cooler, but have not yet many comforts. Such places and others, like
Asheville in North Carolina, are a great improvement on the debilita-
ting and enervating effects of the lowlands of the South.
Georgia, in parts, after all things have been considered, seems to
come nearer the ideal climate for most consumptives than any other
State in the eastern part of our Union, unless it be Eastern Tennessee.
The air is not so dry as in California, but still it is dry. The altitude.
varies so much, that one has only to travel a comparatively short dis-
tance to secure a change of several degrees in temperature. Thus it is
possible to get with ease a climate that is cool enough to excite a
healthy reaction of the system, with the increase of vigor which always
comes with such reaction, like that derived by a healthy man from
surf-bathing, for instance, without enough cold to exhaust the consti-
tution. A consumptive, with vigor enough to withstand the clear cold
of a winter in the Adirondacks or in Minnesota, will be all the better
VOL. 1.-18
274
A SYSTEM OF MEDICINE.
for it; but, unfortunately, most are not strong enough to battle with
such forces, which are out of proportion to the reactive capacity of
their constitutions. Atlanta and the neighboring little village of
Marietta, near the Kenesaw Mountains, 1132 feet above the sea, are
desirable places, with the comforts of life attainable. The winter
mean temperature is 45°, and the summer 75°, at Atlanta. Many
other places in this country will, in all probability, grow into favorite
resorts for consumptives.
In Eastern Tennessee, on the Cumberland Table Lands, are un-
doubtedly many factors favorable for a beneficial climate. Dr. Wright,
of Chattanooga, claims that, on Walden's Ridge in this section, con-
sumption is not an indigenous disease among the inhabitants. So he
states in an essay, "A People without Consumption." Perhaps our
grandchildren may profit and renew their health in this region, but
now it is so uncivilized that few, except the most robust consumptives,
can or will venture into it.
Medicinal treatment, according to the homeopathic method,
calls for remedies to be prescribed after a careful consideration of the
totality of the symptoms, including everything of importance that can
possibly have an influence on the case, to be learned from the past
history, present surroundings, etc. It being impossible in this place
to give anything like a full account of the indications for the remedies,
only the most prominent will be mentioned, the reader being referred
to works on materia medica for the rest.
Tubercular Cachexia.-Calc. carb., Calc. iod., Ferr., Ars., Phos.,
Sulph., Dros.
Indigestion.-Nux vom., Puls., Hydras., Carbo veg., Ars., Kreos.,
Ferrum, Lycop.
Cough. Phos., Hyoscy., Bell., Bry., Calc. carb., Dros., Ipec., Coral-
lium rub., Lobel., Stannum, Kali carb., Antimon. tart., Sang., Rumex,
Lach.
Fever. China, Acon., Baptisia, Antimon. tart., Ars.
Night-sweats.-China, Iodine, Phos. ac., Ars., Sambucus, Pilo-
carpin, Sulph. ac., Nit. ac.
Diarrhoea.-Ars., China, Cham., Puls., Calc. carb., Sulph., Merc.
Hæmoptysis.-Millef., Hamam., Acon., Trill., Secale, Ipec., Ferr.
acet., Ledum, Arn., Ergotin.
Dyspnoea.-Ars., Antimon. tart., Ipec.
Hoarseness.-Spongia, Caustic., Kali bichr., Bell., Kali hydr.,
Rumex, Brom., Iod.
Pleuritic Pains.-Bryon., Arnica, Sulphur. acid., Acon., Kali carb.
A few of the more prominent indications for the twenty-five leading
remedies in phthisis will be given. Other less important remedies,
which may be consulted, but which are here merely mentioned by
name, are: Actea rac., Ars. iod., Ammon. carb., Bapt., Borax, Brom.,
DISEASES OF THE RESPIRATORY ORGANS.
275
Caps., Conium mac., Calc. phos., Dulc., Hydras., Ign., Kali bichrom., Kaolin.
Lauroc., Ledum, Lycopo., Merc., Myrtus, Naph., Nat. mur., Phos. acid,
Sarracenia, Sepia, Silicea, Trill., Verat.
Aconite.-Full, bounding, compressible pulse, with high fever; frequent con-
gestion of the chest; hectic fever; restlessness, with anxious expression of the face;
palpitation; hæmoptysis; pleuritic pains, aggravated by coughing or breathing;
short, dry cough with morning and evening paroxysms; tickling in the throat.
Antimon. tart.-Loose, rattling, hollow cough, worse at night, with suffoca-
tion; rattling of mucus audible to the patients and friends; aggravated by lying
down; cough followed by vomiting; free and copious expectoration; prostration;
afternoon hectic.
Arsenicum.-I have found Ars. one of the most valuable remedies for the
tubercular cachexia, and also for giving relief in those very bad cases where a cure
can hardly be looked for, characterized by the following symptoms: Utter prostration;
rapid emaciation and pronounced hectic; urgent thirst; burning in the stomach;
nausea; diarrhoea; depression of spirits; greatly oppressed breathing; sharp pains
in lung. Ars. iod. is often substituted.
Belladonna.-Violent, spasmodic cough, worse at night and after motion;
congestion of the head, with alternate redness and paleness of the face; bright-red
blood expectorated; aphonia; larynx painful to pressure; dysphagia; perspiration ;
pains at apex and scapular region.
Bryonia.—Tearing dry cough, as if the head and chest would burst; stitching
pains in the sides, catching the breath; symptoms aggravated by motion; sputum
thin, blood-streaked and scanty; soreness under sternum.
Calcarea carb.-A valuable remedy when there is a threatening of phthisis,
especially in young girls with two frequent and too profuse menstruation; or for
scrofulous children, or those with weak bones, slow or difficult dentition, sensitiveness
to cold or damp; poor digestion and assimilation; easily fatigued; epistaxis. After
the disease has actually begun, short, dry, hacking cough in evening and night, with
copious yellow, offensive expectoration, sometimes bloody during the day; dyspnoea
and fatigue on walking up a hill, especially in the morning; good for pale, blonde, leuco-
phlegmatic persons with weak eyes. Calcarea phos. is often substituted, and covers
pretty nearly the same ground. Calc. iod. likewise, especially for the tubercular pre-
disposition.
Carbo veg.-Hard cough, followed by purulent, sometimes fetid expectoration;
nosebleed; sensitiveness to sudden atmospheric changes; afternoon restlessness;
flatulence; sour belchings; fistula in ano; hot hands and sweat on feet; night-
sweats.
Causticum.-Dry cough, aggravated by going from a cold to a warm place;
urine passed involuntarily during cough; cough relieved by cold drink; aphonia
sometimes complete; hoarseness worse in morning.
China.-Copious, exhausting sweats, not only at night, but whenever patient falls
asleep; hectic; prostration after hæmoptysis, seminal emissions, over-lactation, leu-
corrhoea, and diarrhea; weak voice; cough at night, worse after midnight, or after
talking, laughing, eating or drinking; irritability.
Drosera rot.-Paroxysmal cough, somewhat resembling whooping-cough;
paroxysms of variable duration, about two or three hours apart; paroxysms frequently
end with vomiting of mucus or food; cough worse at night and on lying down; pro-
fuse disagreeable expectoration at end of paroxysm; diarrhea; suffocation; hoarse-
ness; pharyngeal catarrh. Tubercular predisposition. Phthisis after pertussis.
Ferrum met.-Anæmia; hæmoptysis; painless diarrhea; epistaxis; œdema
of the lower extremities; patient flushes easily, or has palpitation on emotion or ex-
ertion; is easily fatigued; dyspnoea relieved by warmth; hectic; fulness at stomach ;
vomiting; amenorrhea or watery menses; cough dry at night, but with copious ex-
pectoration of mucus or pus in the morning; symptoms relieved by slowly walking
about. Tubercular cachexia or predisposition.
Hepar sulphur.-Scrofulous patients in the early stage, especially if they are
young; blondes with soft and flabby muscles. Barking, wheezing, choking cough,
excited when any part of the body gets cold from being uncovered; patient sensitive
to open air; sweats easily from exertion and turns pale; burning of palms and soles;
276
A SYSTEM OF MEDICINE.
depression of spirits; scraping and irritation in the larynx, aggravated towards morn-
ing; hoarseness; bubbling rales audible to patient and bystanders; high temperature;
acute phthisis or acute exacerbations of the chronic disease.
Hyoscyamus.-Spasmodic, dry cough, aggravated at night and on lying down;
paroxysms relieved by being bolstered up; headache; dizziness; hiccough; especially
indicated for patients over forty years of age.
Iodine. Adapted to scrofulous people with swollen glands and general emacia-
tion; cough from constant tickling in the windpipe and under the sternum; expecto-
ration of transparent mucus; morbid hunger and yet loss of flesh; morning sweat.
Ipecacuanha.-Asthmatic, suffocative cough, with dyspnoea in paroxysms and
cyanosis; nausea and vomiting; plenty of sonorous and bubbling rales; symptoms
worse at night and in the evening.
Kali carb.-Beneficial both in incipient and in later stages, especially for women
run down after confinement or over-lactation. Nervousness; cough worse about 5
Mucus expelled from mouth forcibly in white globular masses, when coughing;
burning on top of head and on soles; circumscribed red spot on one cheek; constric-
tive pains in chest and throat.
P.M.
Lachesis.-Dry, tickling, croupy cough, worse in the day, with sensation of a
lump in the throat, which is the cause of much hawking and swallowing; offensive
stools; sore mouth in last stage of the disease; cough made worse by touching the
larynx, by mental emotion, and by alcohol; sometimes hoarseness, even to aphonia.
Nux vomica.-Specially indicated for dark-complexioned people, with sallow
skin, of sedentary habits and anxious temperament, also for hard drinkers. Flatu-
lence; heartburn; acid eructations; constipation; dry cough, with irritation in the
pharynx and soreness under the sternum.
Phosphorus.—The king of remedies for phthisis in the writer's experience,
who has seen more recoveries under this than with any other single remedy. Not
only serviceable when the disease seems to be threatening in one predisposed, but also
when it is well advanced. Short dry cough, aggravated by lying on affected side;
pain, soreness or oppression in the chest; burning between shoulders; dyspnoea;
paleness; prostration; emaciation; poor appetite; indigestion; painless diarrhoea;
hoarseness in evening; sometimes aphonia; small, quick pulse; night-sweats during
sleep; almost every kind of expectoration; hæmoptysis; rust-colored sputum; par-
ticularly good for slender persons with fair skin and sanguine temperament, and also
in children, notably delicate girls.
Pulsatilla.-For light-complexioned people, subject to diarrhoea, to whom fatty
food is distasteful, or to chlorotic girls. Dyspeptic symptoms very prominent; moist
cough by day, but dry at night; cough aggravated by warmth; relieved by cool air,
cold drinks, holding the head high and walking; expectoration saltish; scanty or
delayed menses.
Rumex crispus.-Dry fatiguing cough, in long paroxysms, aggravated by cold
air, talking, and pressure on larynx; soreness in trachea, with annoying tickling;
catarrhal hoarseness; cough worse after retiring; left chest oftener affected; brown
watery diarrhoea, early in morning.
Sanguinaria.-Incipient phthisis; dry throat; bad smell, even to patient, of
breath and expectoration; cough loose, but expectoration difficult; chest sore; cold
hands and blue nails; dyspnoea; pain in right chest; phthisis in syphilitic patients;
circumscribed redness of cheeks; cough worse on lying down; loose stools; lassitude
in the evening.
Spongia.-Dryness of larynx; hoarseness; aphonia; sudden giving way of voice;
contraction of glottis; paroxysms of dyspnoea; hoarse, hollow, wheezing, dry cough,
aggravated by warmth; crowing; exhaustion in chest after exertion; chilliness in back
not removed by heat.
Stannum.—Profuse mucous expectoration in first stage; afterwards profuse yel-
low or green, sweetish expectoration, with forcible expulsion of small balls; loose
cough; great exhaustion; weakness of legs; too weak and short of breath to talk
more than two or three words at a time; empty feeling in chest; bloating of stomach
after eating; hands and feet cold, or else hot; profuse night and morning sweats;
chill at 10 A.M.
Sulphur.-Soreness in upper part of left lung, going through to back; patient
complains of being too hot, and wants to keep his feet outside of the bedclothes; cough
mostly dry, with now and then a profuse discharge of purulent matter; palpitation;
DISEASES OF THE RESPIRATORY ORGANS.
277
profuse night-sweats; diarrhoea early in the morning; no appetite for breakfast, but
faint long before dinner; emaciation and debility; dyspnoea; leucorrhoea; too profuse
and frequent menses; long, lingering cases, that seem to improve and then relapse;
frequent slight attacks of hæmoptysis; for patients of melancholy lymphatic tempera-
ment, subject to venous plethora and hæmorrhoids, scrofulous eruptions, abscesses,
boils or glandular swellings.
Adjuvants. The cough can often be allayed somewhat by simple
means in addition to the homeopathic remedy. Such are sipping from
time to time a little glycerine and water, barley-water, gum-arabic water,
rice-water, Iceland-moss tea, flaxseed tea; or chewing up occasionally
slippery elm bark, or letting simple candy, or cocoa-butter, or gum-arabic
dissolve slowly in the mouth. The patient should be taught to restrain
the cough as much as possible. Surely not all, but a part of the cough-
ing, can be controlled by an effort of the will. Some remedies may be
given by inhalation with good effect; especially, Iodine, Kreasote, Car-
bolic acid (for fetid breath and expectoration), Aconite, Hyoscyamus,
Belladonna, Ipecac., Bryonia, and Phosphorus; also Tar. If dryness.
of the throat is caused, a little glycerine should be swallowed before in-
haling. A regular steam-atomizer or other inhaler may be used, or
one extemporized from a jug or tea-kettle; and the inhalation may be
kept up from five to fifteen or twenty minutes, twice a day. The
fumes of benzoin or resin may also be inhaled, or a few drops of sul-
phuric ether. Chloroform, although temporarily effective, is too dan-
gerous for the patient to handle alone. When the case is hopeless, and
the cough very distressing, physiological doses of belladonna, conium,
hyoscyamus, hydrocyanic acid or morphine may be given. These,
particularly the latter, should be given only as a last resort. The
morphine should be given in as small a dose as possible, from the g
of a grain to the of a grain in granules, parvules, or gelatine or sugar-
coated pills. The unpleasant effects of the morphine can often be pre-
vented by the addition of sulphate of atropine. Gelatine-coated pills
are made combining of a grain of the former with of a grain of
the latter.
(6
For night-sweats the hot bath has been already spoken of under
'Bathing." The patient may instead be sponged over with vinegar
and water, or what is more pleasant, acetic or sulphuric acid with
cologne and water, at bedtime for several nights in succession. From
two to four grains of oxide of zinc at bedtime will often prove success-
ful; or the hypodermic injection of the sulphate of atropine in doses
of from 0 to 1 of a grain, or the administration by the stomach of
the same in doses of of a grain, or five minims of the second decimal
dilution of muscarin. Pierotoxin in doses of of a grain at bedtime
is strictly homœopathic. A tumblerful of milk or other simple food in
the night sometimes works well.
200
During hæmoptysis, if at all severe, the patient should be put to bed
in a cool room, and kept perfectly still, forbidden to talk, and asked to
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A SYSTEM OF MEDICINE.
restrain his cough as much as possible. All food and drink should be
cold. He and the friends, who are often much excited, should be
calmed as much as possible, by informing them that more blood may
very likely come, but that it is exceedingly rare for any one to bleed
to death. Diet must be very simple and nourishing, without alcohol.
Ice may be sucked, but it is generally inadvisable to put ice in a blad-
der or rubber bag on the patient's chest. The tincture of Hamamelis
may be given in two or three drop doses every whole, half, or quarter
hour, according to the amount of hæmorrhage. A shawl-strap about
one of the limbs in severe cases may be of service, and the urine
should be drawn for several days, unless the patient can use the bed-
pan when lying on his back. A physical examination should not be
made until some days after bleeding has ceased.
Diarrhea and constipation should be regulated as far as possible by
appropriate diet. Pleuritic pains may be helped by cold compresses,
hot fomentations or poultices. As to the propriety of operating upon
fistula in ano in a phthisical patient the best authorities differ. For
pains in the bowels hot applications, wet or dry, should be applied;
and when they are very severe, as sometimes in the last stages, Mor-
phine should by all means be given for humanitarian reasons.
Bed-sores are very apt to form in the last stage of the disease. When
threatening, the reddened skin should be toughened by bathing in
alcohol, or protected by collodion, and the patient should be placed on
a water-bed or air-bed. If the bed-sore has actually formed, it should
be dressed with calendula infusion or cerate, vaseline, carbolic acid,
absorbent cotton or oakum, or strapped with adhesive plaster. The
pressure should invariably be removed and be brought to bear on the
surrounding parts by means of an air- or down-cushion, used on the
same principle as a corn-shield.
The injection of lung cavities through the chest-walls by means of
an aspirator-needle, or through the larynx, with different substances,
has been attempted often enough to show that it is of no practical
benefit. The inhalation of oxygen, hydrogen, and nitrous oxide also
has failed to give satisfaction; but much good can often be done
mechanically in the way of distending unused air-cells thoroughly
and safely, for the weak as well as for the strong, by the inspiration
of slightly compressed air.
PULMONARY CONGESTION, EDEMA, HÆMORRHAGE, AND
APOPLEXY.
BY A. K. CRAWFORD, M.D.
Definition.-An undue accumulation of blood in the capillary
vessels of the lung, leading to extravasations into the air-cells, the
bronchioles, or the pulmonary connective tissue.
DISEASES OF THE RESPIRATORY ORGANS.
279
Pathology. There are several forms of excess of blood-pressure
in the lungs, as well as degrees and conditions of hæmorrhage, to
which distinctive names have been applied, but which are so often
only stages in the same process, and are so frequently coexistent in
the same person, that they are better considered under one head.
Hyperæmia and congestion are used synonymously for any active,
passive, or mechanical stasis of blood in the pulmonary or bronchial
vessels. The lung in this condition is of a dark-red color, grading,
down to almost a black, according to the amount of blood and pigment.
present. The engorged portion is larger and heavier than normal, but
floats in water. It gives diminished crepitation under the fingers, and
a frothy, bloody fluid escapes when it is cut.
Hypostatic congestion is a more advanced state of engorgement,
in which the lung is found to be somewhat friable and the vesicular
structure barely visible. This condition of the lung has been termed
"splenified," and it can very readily develop into hypostatic pneu-
monia.
Edema of the lungs is associated usually with oedema elsewhere,
and is essentially the same in either situation. The serous transuda-
tion occurs in the air-cells especially, more marked in the pendent
parts. The lung does not collapse when the chest-wall is opened, and
its surface pits on pressure. More or less watery fluid escapes when
the tissue is cut, mixed with blood in proportion to the degree of con-
gestion accompanying the oedema.
Hæmoptysis is a discharge of blood, indicative of a hæmorrhage
into the air-passages, and is, therefore, a symptom common to the
many maladies in which pulmonary hæmorrhages occur.
These ex-
travasations of blood appear under several different forms. That
which is known as the diffuse form results from the rupture of a vessel
of some size, although recent and careful examination of such lungs
has shown that hæmorrhages rarely occur from the larger vessels.
But the lung tissue is always torn, and, as a consequence, we have an
irregular cavity, containing clotted and fluid blood in varying propor-
tions. Another form of hæmorrhage is the circumscribed or pulmonary
apoplectic. It is limited in extent, nodular in appearance, and firm to
the touch. Those occurring in the centre of the lung are usually
larger than those found near the surfaces. The latter often occupy
the space of a single lobule, and are then wedge-shaped, presenting
some of the characteristics of consolidation in lobular pneumonia.
But when section is made through the nodule, it appears of a dark-
red tint, somewhat granular, and contains clotted blood. On remov-
ing some of this blood the lung-tissue can be seen. Often several of
these circumscribed hæmorrhages occur at once, and their most fre-
quent seat is in the centre of the lower lobes, or near the root of the
lung. There is no rupture of tissue, as in the diffuse variety, and the
280
A SYSTEM OF MEDICINE.
pulmonary capillary vessels which supply the blood pour it into the
alveoli and the finest bronchial tubes, and the adjacent tissue is found
to be more or less congested. Pulmonary apoplexy is also known by
the name of "hæmorrhagic infarction," and includes pulmonary throm-
bosis and embolism in its pathology. The central vessel of a circum-
scribed hæmorrhage is discovered to be blocked, partially or wholly,
by a clot, and these clots are now looked upon as emboli, carried
thence through the venous circulation, as a rule, from some distant
and disintegrating thrombus.
Why an obstructed vessel will cause a hæmorrhage to occur from
the capillaries in its neighborhood, has not yet been satisfactorily ex-
plained. The appearance and condition of the infarction change.
with its age. It pales and becomes more solid on account of absorp-
tion of the coloring matter and of the fluid portion of the blood.
Sometimes the extravasation is entirely absorbed, sometimes it develops
pneumonia or abscess, or becomes encapsuled, but more often the
remnant of the apoplectic clot is nothing more than a permanent pig-
mented induration. Other forms of pulmonary hæmorrhage are the
interlobular and the petechial, but as these occur but seldom, descrip-
tion in detail is unnecessary.
Causation.-Active congestion results from such causes as give
rise to pulmonary inflammations, from interfering with the act of
respiration or of the capillary circulation, from irritating vapors, and
from greatly increased action of the heart. Mechanical congestion is
due most frequently to mitral disease, or it may result from a weak-
ened left ventricle, or from the pressure of a tumor on the pulmonary
veins. Passive congestion is a concomitant of low fevers and of such
states as depress the heart's action. It is in advanced life and in those
prematurely enfeebled that through, possibly, a weakened right ven-
tricle or disturbed capillary circulation, hypostatic congestion is in-
duced.
The mechanical causes of the development of adema are usually
found to be a mitral regurgitant lesion, or the effect on the lung of a
general anasarcous condition. It is also often traceable to renal dis-
orders, but how the latter produce pulmonary edema is not clear.
There are reasons for believing that none of the causes mentioned are
the most common or the most potent factors in developing œdema.
When it is considered that oedema of the lungs oftentimes exists with-
out other tissues in the body being implicated in like manner, and
that the reverse is also true; when it is noticed with what suddenness
it develops in some cases of acute nephritis and of pregnancy; when
it is frequently seen to invade only portions of the lungs, or of one
lung, and to leave the remainder normal; when we remember that
conditions which affect other tissues do not act on the lungs in a
manner calculated to produce an oedematous state, such as the injec-
DISEASES OF THE RESPIRATORY ORGANS.
281
tion of large quantities of saline solutions, then it would seem well to
look beyond a mechanical agent as the sole cause of œdema.
In the early part of this century, Edwards, Breschet, and Vasseur
showed that division of the pneumogastrics in animals causes in them
death from oedema of the lungs. Other experiments, made by Cohn-
heim and Lichtheim, have shown that mere additional pressure of
blood in the pulmonary vessels will not produce transudation of
serum. So that pulmonary ademas may be attributable to vaso-motor
paralysis, which enervates the tissue composing the vessel walls, giving
rise to serous osmosis. Equally interesting experiments have been.
made in regard to the heart and the production of oedema of the lungs,
and from these, with certain clinical cases cited by Falk, it has been
determined that a paretic condition of the left ventricle, causing an
arhythmical action of the venous and arterial sides of the heart, will
produce pulmonary edema.
Hæmorrhages and hæmoptysis result from congestion of the lungs,
from rupture of any of the pulmonary tissues, from diseases of the
heart or lungs or arteries, from pneumonia, phthisis, cancerous or
other growths, thoracic aneurisms, ulcers, or from the lodgment of
emboli in the pulmonary vessels. They occur also in consequence of
injuries about the chest, from straining, from a sudden change in at-
mospheric pressure, as in ascending a high mountain, and sometimes
without apparent reason in plethoric individuals.
Hæmoptysis is seen likewise in malignant fevers, in purpura, and
other blood disorders, and occasionally it appears to be hereditary. It
was formerly supposed that the firm tissue inclosing a cavity in the
lungs contained no vessels, but such is now known not to be the case.
Not only that, but the blood vessels in this condensed tissue are fre-
quently aneurismal, and their rupture into the adjacent cavity pro-
duces the gravest hæmorrhages. In amenorrhoea a compensatory
hæmoptysis has been observed, but this is of rare occurrence, and
when it appears it assumes the periodicity of the menstrual flow.
Symptoms and Physical Signs.-These, as a rule, are not very
definite. Perhaps quite suddenly, a cough or a tickling sensation in
the throat brings about an expectoration of a profuse watery fluid if
the condition be œdema, or more or less blood if it be hæmorrhage.
Occasionally, a sense of weight in the chest, and of heat, or of pain be-
tween the shoulders, palpitation and dyspnoea, may be complained of
by the patient for a few days before the attack occurs. The dyspnoea
is probably the most prominent symptom at first, especially if the
hæmorrhage is large. Then there will be gurgling sounds heard in
breathing, much weakness, or even complete prostration of the patient,
while the pale and pinched face presents the expression of anxiety
and alarm. The quantity of blood lost by pulmonary hæmorrhage.
is sometimes so great as to cause complete syncope, and this serves
282
A SYSTEM OF MEDICINE.
the purpose of arresting the flow. If a hæmorrhagic clot sets up an
inflammation in the pulmonary tissue, febrile symptoms will mark
its development.
Hæmorrhages which are sudden, profuse, and violent, and without
prodroma, are ordinarily from the rupture of an aneurism, and may
within a few moments cause the patient's death.
The severity of the symptoms in pulmonary apoplexy will depend
on the number and extent of the hæmorrhagic infarctions. So the
symptoms may consist only in an increase of those already exist-
ing, indicative of valvular disease of the heart. Or they may be such
as sudden orthopnoea with threatening suffocation, cough, expectora-
tion of blood, coarse rales, the face bordering on a purplish tint, and
the pulse small and frequent. If the patient survives the onset,
pneumonia or pleurisy commonly starts up around the site of the
hæmorrhage.
The physical signs of congestion are inappreciable, unless it is ac-
companied by oedema or hæmorrhage.
In oedema we find some dulness on percussion, usually on both
sides and more marked posteriorly. By auscultation a crepitant rale
is heard, resembling somewhat that noticed in the first stage of pneu-
monia; in oedema the rale is more moist.
Even in slight hæmorrhages the ear may detect moist rales over a
limited area. When the hæmorrhage is to any degree extensive, there
will be a corresponding amount of dulness on percussion, with weak-
ened or absent respiratory murmur, and an abundance of moist rales,
heard until the fluid blood is coagulated or resorbed. The locality of
apoplectic nodules cannot be defined unless they are both large and
superficial. In the latter instance, besides the signs already given,
there may be bronchial breathing and augmented vocal sounds, be-
cause of the hæmorrhage being close to a bronchial tube.
Diagnosis. Between pulmonary hemorrhage, pneumonia, and
hæmatemesis there are some general signs in common. But in
hæmoptysis the blood expectorated is pure, either bright or dark
brown, and without air. In pneumonia it consists of mucus, blood,
and air-bubbles finely intermixed. In hæmatemesis it is usually
black, of an acid reaction, attended with nausea, and afterwards black,
tarry stools are passed. The dyspnoea of hæmorrhage is greatest at
first; that of pneumonia increases as the disease progresses, up to the
commencement of resolution, and the former is accompanied with less
fever than the latter.
The existence of dulness on percussion contraindicates acute bron-
chitis, and the difficult breathing is never so marked in the bronchial
inflammation. The discovery of pulmonary signs or of heart-disease,
when there is doubt as to whether the blood had its source in the
stomach or lungs, will decide in favor of pulmonary hæmorrhage.
DISEASES OF THE RESPIRATORY ORGANS.
283
Prognosis. The prognosis in these affections is not at all favor-
able. In congestion of the lungs it is all the more serious if it is com-
plicated with some low form of fever, and the outlook of hæmoptysis,
especially if the hæmorrhages are frequent, is towards a fatal issue.
As hæmoptysis is almost invariably linked with some organic affec-
tion, there is but little prospect of the patient ever being out of dan-
ger; but it may be years, as in some cases of phthisis, before a fatal
termination ensues. When the hæmoptysis has been slight, and no
marked febrile action follows within a few days, the patient will prob-
ably recover.
Treatment. To allay the excitement of both the patient and
friends, which always attends an occurrence of blood-spitting, is some-
thing the physician must needs meet early in his treatment of the
case. And as soon as practicable the patient should be put to bed,
propped up in a half-reclining posture, covered with light clothing,
and in the utmost quiet. The room should be kept cool, and it is
even recommended that the patient should breathe through an ice
respirator. A very light diet should be prescribed, consisting of
broths and milk, and these preferably given cold. The application
of ice or of chloroform to the chest over the site of the hæmorrhage
often proves of service. Constricting the limbs with bandages, so that
the return circulation of the blood is impeded, and a considerable
quantity thereby retained in the peripheral vessels, also aids in arrest-
ing the hæmorrhage.
When the hæmoptysis is continuous, and seems liable to interfere
with the administration of a remedy by the mouth, and especially if
a very speedy action of the medicine is desired, the hypodermic
syringe should be used.
Arnica is the first remedy to be thought of if the hemorrhage comes from vio-
lence or over-exertion. The blood is abundant, dark, and clotted, and the patient is
despondent.
Aconite is indicated in active hæmorrhages when there is high arterial tension,
flushed face, great anxiety, an incessant cough, with abundant expectoration of red,
frothy blood. Hughes says he has never had occasion to use it, but relies on
Millefolium and Hamamelis.-The former is given for a painless hæm-
orrhage of light-colored, fluid blood, with but little cough, and the latter for a passive,
dark-colored venous hæmorrhage. According to Jousset, Millefolium in the treatment
of hæmoptysis has the preference among physicians on the continent. It acts well in
cases complicated with amenorrhoea, or suppressed lochia, and also in tubercular, car-
diac, and supplementary hæmoptyses. On the other hand, Hamamelis is probably
the remedy most frequently employed by homeopathists in this country for pulmonary
hæmorrhage. It is very efficacious when there is difficulty in breathing, the patient
being unable to lie down; there is a feeling of constriction across the chest, tickling
cough, a taste of blood or of sulphur is experienced, and the blood, as before stated, is
venous in hue.
Ipecacuanha is indicated where there is a tickling sensation behind the
sternum, with more cough than attends a Hamamelis case. The patient requiring
Ipecacuanha often describes a sensation of bubbling in the chest prior to an abundant
expectoration.
Digitalis purpurea may be used in cases of hæmoptysis due to embarrass-
ment of the pulmonary circulation through heart-disease. The veins about the head
248
A SYSTEM OF MEDICINE.
are engorged; the face is pale and livid; the skin cold; the pulse irregular, with
throbbing of the heart. There is great distress in breathing, anxiety, restlessness, and
a disposition to faint. If the lungs are tubercular, these symptoms are all the more
marked indications for Digatalis.
Cactus grand.-Another special heart remedy. It is indicated in hæmoptysis
from cardiac disease when that organ is turbulent in its action. There is less fever
and restlessness than in Aconite, and it has the constrictive sensation of an iron band
about the heart.
Ledum palustre is recommended for a profuse hæmoptysis of red and frothy
blood. The cough is violent and spasmodic, from a tickling sensation in the larynx
and trachea, and the pulse is strong.
Arsenicum album is occasionally indicated when a prostrated, irritable con-
dition is found in connection with an excessive cardiac excitability. It is of little
value in hæmoptic phthisis, but stands in support of Digitalis in cardiac affections.
Phosphorus is rarely used now in the active stage of hæmoptysis. But when
inflammation threatens after a hæmorrhage, and when there are signs of tuberculosis,
with a hoarse voice, dry frequent cough, tickling below the larynx, and rapid, panting
respiration, it is plainly needed. The hæmorrhagic diathesis is another prominent
indication for this remedy.
Ferrum aceticum is found to supplement Millefolium when, in addition to
the symptoms for the latter remedy, there is a dry, tickling cough and spitting of
bright, coagulated blood.
In the form of the perchloride, Ferrum has been considerably in vogue for persistent
and profuse hæmoptysis, and with some degree of success. It is usually administered
in appreciable doses.
Gallic acid is also of great service in these cases of chronic and stubborn
hæmorrhage.
The
Probably the greater part of the treatment demanded of us for cases of pulmonary
hæmorrhage is not so much for the hemorrhage itself as for the effects of the attack,
for the constitutional condition inducing the attack, and for the prevention of its recur-
rence. Such being the case, the therapeutic field must be an unlimited one.
remedies to be given in each case during the intervals between the hæmorrhages
must be chosen with reference to the etiological factor of the hæmoptysis; and this
will oftentimes require the finest diagnostic skill.
There are many remedies besides those already given which have
proved efficacious in pulmonary hæmorrhages in different hands,
some of which are herewith enumerated, with the conditions in which
they are found most frequently useful.
For ACTIVE pulmonary congestion: Aconite, Arnica, Belladonna,
Millefolium, Nux, Trillium, Verat. vir.
For PASSIVE pulmonary congestion: Arsenicum, Digitalis, Hama-
melis, Erigeron, Ipecacuanha.
For MECHANICAL pulmonary congestion: Cactus, Digitalis, Ledum,
Arsenicum.
For pulmonary EDEMA: Phosphorus, Digitalis, Tart. emetic, Ar-
senicum.
For VICARIOUS hæmoptysis: Pulsatilla, Bryonia, Senecio.
For hæmoptysis due to TUBERCULOSIS: Aconite, Arnica, Pulsatilla,
Millefolium, Ledum, Phosphorus; due to CARDIAC disease: Aconite,
Cactus, Digitalis, Arsenicum; due to EMPHYSEMA and ASTHMA: Cu-
prum, Ipecacuanha, Arsenic, Nux, Bryonia, Digitalis, Carbo veg.; due
to CATARRH: Belladonna, Hyoscyamus, Mercurius, Scilla.
For PNEUMONIC INFARCTIONS: Arnica, Bryonia, Digitalis, Phosphorus,
Mercurius.
DISEASES OF THE RESPIRATORY ORGANS.
285
For the prevention of the return of hæmoptysis, study Calcarea car-
bonica, Carbo. veg., Conium, Ferrum, Sepia, and Silicea.
EMPHYSEMA PULMONUM.
BY A. K. CRAWFORD, M.D.
Synonyms.-Latin, Emphysema; French, Emphysème; German,
Emphysem; Italian and Spanish, Enfisema.
Varieties. The presence of air in the areolar tissue is the condi-
tion to which the term emphysema applies in general. It presents
itself on the body in the form of a puffy, shining, indolent tumor, which
conveys a sense of crackling to the touch, and which is the outcome
of gaseous formation, or extravasation of air into the connective
tissue. According as it is traceable to external violence or some in-
ternal derangement, it is called symptomatic or idiopathic.
The application of this term to the lungs formerly meant precisely
the same condition as that found in the body, viz., air in the connec-
tive tissue. But since the time of Laennec another form of pulmonary
distension with air has been acknowledged to exist, and, consequently,
the term now obtains a wider significance. Air in the areolar tissue
of the lungs, from its anatomical position, receives the name of inter-
lobular or interstitial emphysema. It is the same form which, at times,
permeates the subpleural tissue; and in either case it is so commonly
the result of injury to the thorax, that it more properly belongs to the
field of surgery.
The variety with which we have to do, is that first clearly described
by Laennec, and which he named vesicular emphysema. This applies
to an excess of air in the air-cells of the lungs, and because of the
state of expansion of the air-vesicles which this induces, it is some-
times referred to as dilatation of the air-cells. The extent of lung
tissue involved in vesicular emphysema has given rise to its sub-
division into partial, lobular, and lobar emphysema. The first refers to
emphysematous patches affecting only a few air-sacs scattered along
the margins of a lobe. It is generally seen in connection with the
second form, or lobular, which implies that one or more lobules have
been subjected to the disease throughout the lung. The lobar, of
course, refers to the involvement of a whole lobe, or, perhaps, does
not stop short of all the tissue of a lung. This form is less frequent,
but much more serious than the lobular. The terms vicarious and
substantive have been used to express emphysema developed from
supplemental respiration in the one instance, and in the other from
some source inherent in the individual.
Pathology. The most marked feature of the altered pulmonary
286
A SYSTEM OF MEDICINE.
tissue, and the one which precedes all other visible effects, is the
enlargement and permanent distension of the air-cells. They may
attain such size that they become visible on the external surface of
the lung. The whole lung increases its bulk, and when the thorax is
opened it does not collapse like healthy tissue, but often bulges out
instead. When pressed with the fingers, there is much less crepita-
tion than is felt in the normal lung, and much of its contractile power
is lost. The spaces existing in an emphysematous lung are probably
the result of the junction of many cells, through destruction or rup-
ture of their septa, and when a dried specimen is cut, the spaces are
found to vary from the size of a pin's head to an almond-kernel.
The direct result of the increased intra-pulmonic pressure and the
coalescence of the air-vesicles is the contraction and, often, oblitera-
tion of a share of the capillary blood vessels distributed through the
lung tissue. The aerating surface of the lung is also very much.
diminished in extent. Therefore the dilated or diseased portion of
the pulmonary texture is pale, anæmic, and drier than normal. The
interference with the capillary circulation reacts on the heart, and
there develops a right-sided dilatation, or dilated hypertrophy. The
increased size of the lungs displaces the heart as well as the diaphragm,
with the viscera below it. The bronchial tubes frequently become
dilated, and intercurrent attacks of bronchitis are common. Usually,
both lungs are involved to a greater or less extent, although the left
is apt to be most affected. Louis puts it that the emphysematous
state is greatest, as a rule, in the upper portion of the right lung and
the lower portion of the left.
Clinical History.-Emphysema is of necessity a chronic affection,
and belongs to a class of non-inflammatory pulmonary diseases. No
fever is ever discovered, the surface of the body remains cool, and
the pulse is weak. The obstruction to the circulation in the lungs,
and the distension of the right heart, result in venous congestion and,
occasionally, cyanosis. At first, when there is still sufficient healthy
tissue to aerate the blood, there is no distress in breathing. But
usually the patient does not apply for medical aid until the damage
is so great that the breathing, even in the state of repose, is labored,
especially in expiration. It will be seen then that the rhythm of
respiration is abnormal, the inspiration being shortened and the
expiration lengthened. An extensive lobar emphysema sometimes.
develops quite rapidly in both lungs, and runs a much more acute
course than the ordinary form, the latter really having no definite
limit to its duration, but continuing and augmenting throughout life.
The presence of emphysema seems to be unfriendly towards the de-
velopment of tubercle, and it is rare that pneumonia ever occurs as a
complication. Asthma is a frequent associate of emphysema, and
adds materially to the discomfort of the patient.
DISEASES OF THE RESPIRATORY ORGANS.
287
Causation. The theories of the mechanical production of disten-
sion of the air-cells of the lungs are manifold. Laennec thought it
was occasioned by the inability of the expiratory act to force the in-
spired air through a viscid mucous plug, and the volume of impris-
oned air being increased by each inspiration, dilatation of the air-
vesicles resulted. As this opinion was based on the supposition that
inspiration was stronger than expiration, it does not agree with the
physiology of to-day, and, consequently, it has been dropped. That
the dilatation occurs in connection with, or in consequence of, a bron-
chial catarrh, is agreed to by most pathologists, and the manner of its
development therefrom may be stated as being the result of inspira-
tion or of forced expiration. An example of the former may be had
from the perusal of Gairdner's views, wherein he takes the ground that
the plugs of mucus situated as Laennec described them produced
collapse, and not dilatation, of the air-cells, and that the proximate
cells compensated by dilating. Examples of the expiratory act caus-
ing distended vesicles are such as blowing on wind-instruments, and
the act of coughing. Sir William Jenner gave the minutiae of the
effects on the lungs of coughing years ago, and Waters has since
added his theory thereto. They hinge mostly on the partial closure
of the glottis, and the concussive force of the cough expending itself
within the lungs. But Louis comes to the conclusion that catarrh
has but little influence in producing emphysema, because he found
that the oppressed breathing and dyspnoea, in those having this dis-
ease, preceded the bronchial trouble and cough for a considerable
time. And Waters, while he regards the production of the lobular
variety as due most likely to catarrh and cough, believes the lobar
and more severe forms to be a constitutional disease, and that its
primary effect is malnutrition of the pulmonary tissue, and its sub-
sequent degeneration. The four-fold reason given for this view is
that emphysema develops extensively before there is any history of
cough, that both lungs are attacked and the morbid changes are
uniform throughout, that it is hereditary, and that the disease is bene-
fited by treatment such as is prescribed for degeneration of tissue
elsewhere. The conclusion to be arrived at is, therefore, that emphy-
sema results from two distinct causative agents, the one mechanical,
the other constitutional.
That there is a hereditary tendency towards the production of em-
physema is shown by observations such as Greenhow has made. Out
of forty-two cases he found twenty-three of them were of emphyse-
matous parents. And Jackson discovered the same relationship in
eighteen out of twenty-eight cases closely studied.
Emphysema is often produced by pertussis, and it is caused by, and
in its turn complicates, bronchitis. It has been already stated that
tuberculosis seldom develops in an emphysematous lung, but it is
288
A SYSTEM OF MEDICINE.
none the less true that emphysema does frequently develop in a tu-
berculous lung. It is in this case of the lobular variety, and is an
attempt on the part of nature to compensate for the solidified tuber-
cular spots.
Symptoms and Physical Signs.-The symptom which is most
noticeable to the patient is the difficulty in breathing; while striving
constantly, he never succeeds in getting a satisfactory full breath,
and a little exertion out-winds him completely. The cough which
usually attends emphysema belongs more to the concomitant chronic
bronchitis, and the amount and quality of the expectoration vary
considerably. It is always with difficulty that any sputum is raised ;
this may exceptionally be streaked with blood, but usually it is clear
and frothy, and not unlike soapsuds. There is so much difficulty
connected with the expiratory act, that a cough occasions considerable
torture. It partakes of the nature of whooping-cough, is violent, spas-
modic, and exceedingly exhausting. The face shows some of the
bluish tint due to obstruction of the pulmonary circulation, and be-
sides becoming puffy, it wears a distressed expression, and has a dingy
hue. The appetite may not become affected for a considerable time,
but eventually it wanes, and more or less emaciation follows. When
the disease is far advanced, the growing hypertrophy or dilatation of
the right ventricle shows its influence by producing palpitations, gen-
eral anasarca, and, may be, dropsical effusion.
The physical signs of emphysema are determined by means of in-
spection, percussion, and auscultation. None of the other artifices of
examination give any reliable data unless it be that of mensuration.
The chest of an emphysematous patient presents such changes to the
eye that by this means alone strong evidence of the existence of the
disease is furnished. Both sides are more than usually prominent,
attaining such a full convexity that it has had applied to it the name
of " barrel-shaped." The intercostal spaces are widened in the upper
part of the chest, and narrowed in the lower. The respiratory act is
labored, yet there is little or no expansion of the upper chest. The
chest wall rises and falls almost vertically; often, too, the supra-cla-
vicular region, as well as the lower segment of the thorax, sinks in
during inspiration, and the breathing accomplished is mostly abdomi-
nal. The percussion note is clear, lowered in pitch, and increased
beyond the normal; it has become very generally known and described
as the vesiculo-tympanitic. By auscultation the respiratory sounds
are found to have changed to a short and feeble or, sometimes, absent
inspiratory murmur, while the expiratory is prolonged, thus reversing
the usual relative proportion of time the one occupies to the other.
Occasionally, the respiratory murmurs have been described as harsh
and sibilant and of equal length. From the nature of these sounds
they must be developed in lesser-sized and contracted bronchi.
DISEASES OF THE RESPIRATORY ORGANS.
289
Diagnosis. If any question arise as to whether a given case may
be one of emphysema or of pleuritic effusion, it may be determined
by finding, in the latter instance, that the percussion clearness in the
upper part of the chest is replaced by dulness below, over the accu-
mulation in the pleura. Sometimes growths in the mediastinal space,
or an aneurismal tumor, will cause such bulging of the chest wall as to
suggest emphysema. But the dull percussion sound over every solid
mass hidden there, and the pulsation and murmurs of an aneurism,
will be efficient to separate those from the lung affection. In pneumo-
thorax we have the disease of all others most closely simulating em-
physema. Both present an enlarged chest; both cause displacement
of the viscera; both are accompanied with dyspnea; both have clear-
ness on percussion, but in this sign we find our first point of diver-
gence, for the quality of this clearness is distinct in each. The per-
cussion sound of emphysema still retains part of its pulmonic quality,
and this modifies the increased resonance. But in pneumothorax
percussion produces an absolutely tympanitic note. Moreover, be-
cause of the almost invariable pleuritis that occurs secondary to pneu-
mothorax, in the signs of the latter affection there will be some dul-
ness over the pendent portion of the pleural cavity, and by auscultation
some splashing sounds. Emphysema involves both lungs, as a rule,
while pneumothorax is almost certain to be found in but one.
Prognosis. From the pathological character of the changes in this
disease, it is not difficult to sum up its ultimate outcome. When the
emphysematous lung still possesses the alveoli of the cells intact,
the disease is not beyond repair. But when the septa are absorbed,
broken down, or destroyed, there is no possible chance for recovery.
In neither case is there any prospect of speedy death. The disease
runs along, gradually lessening the physical strength of the individual,
increasing the risk if another disease sets in, and making life misera-
ble generally, because of the limitations imposed on every exertion
attempted by the patient, and the constant dyspnoea. The symptoms
which develop towards the close of an uncomplicated case of emphy-
sema point more strongly to the failure of the circulatory system than
of the respiratory.
Treatment. The patient should be warned against taking an
undue amount of exercise, and great care should be used in the selec-
tion of food. The flatulence of indigestion increases the distress in
breathing, and disturbs the heart by its pressure. Imperfect assimi-
lation 'is one of the first states to be overcome before a building-up or
a recuperative process can be established. Therefore the food should
be plain, nutritious, easy of digestion, moderate in quantity, and
sparing in its fluid constituents. By this means there will be a lessened
amount of blood to pass through the deficient lung without lacking in
nutritive elements.
VOL. I.-19
290
A SYSTEM OF MEDICINE.
An atmosphere free from miasms and poisons of all kinds should
be chosen to live in, and the patient will be better for being consider-
ably in the open air, walking or driving leisurely.
The remedies for this disease must be chosen with reference to the
intercurrent affections, when they are present, and to the tissue
changes in the lungs; in the first case, to relieve or dispose of an
attack of asthma or bronchitis, for instance, and in the second, to stop
the progress or restore the damage done to the air-cell.
Under the separate heads of functional gastric and cardiac troubles,
and under bronchitis, acute and chronic, as well as asthma, the proper
remedies will be found from which to choose in the treatment of em-
physema. The following deserve particular mention:
Tartar emetic is specially indicated when the secretion in the bronchial tubes
is very difficult to raise.
Carbo vegetabilis, when the quantity of mucus is greater, and is expecto-
rated easily.
Arsenicum, for the chronic but scanty secretion of a white, glairy mucus.
Lobelia will relieve the distress of an occasional smothering in the chest much
complained of in emphysema.
Lycopodium stands first among the remedies for intestinal complication. The
indications for it are a catarrhal, flatulent and constipated condition of the bowel.
Digitalis is of service when the dyspnoea is increased by a weak state of the
heart, and Bæhr speaks of
Natrum mur., relieving a distressing case of cardiac involvement.
Bryonia and Mercurius will probably best suit an attack of acute bronchitis
while the fever prevails, after which
Phosphorus, Tart. emetic, or some other of the catarrhal remedies will be re-
quired to complete the treatment.
We are, as yet, so much in the dark in regard to the process which
induces the destructive change in the air-vesicles, that it is impossible
to base a therapy on our pathology. As there exists something of an
analogy between this pulmonary degeneration and that of Bright's
disease, or of the fatty heart, the remedies for these affections deserve
our careful attention. Phosphorus would seem to be ruled out of the
list of those likely to be of service, because it is claimed that the de-
generation of the septa of the cells does not take on the fatty form.
But the deeper acting tissue-remedies that are held to be useful in
those other destructive diseases, should always be kept in mind. They
are Aurum muriaticum, Arsenicum, Cantharides, Cuprum aceticum,
Hepar sulph., Mercurius cor., Nitric acid, Phosphoric acid, Plumbum,
and Silicea.
APNEUMATOSIS-ATELECTASIS PULMONUM.
BY A. K. CRAWFORD, M.D.
Synonyms. Pulmonary collapse, Pulmonary compression, Carni-
fication; Latin, Atelectasis; French, Atelectasie; German, Atelectasis;
Italian, Atelettasia.
DISEASES OF THE RESPIRATORY ORGANS.
29.1
Definition. The terms mean "without air," and are applied to an
imperfect expansion of the lungs, or the total absence of air in the
lungs, like their normal condition in fœtal life. When the pulmonary
tissue has not yet been unfolded, the name Atelectasis is applied.
When through some means, external or internal, the air-cells, having
been dilated, again become solid, Dr. W. T. Gairdner called it pul-
monary collapse; but when the same occurrence takes place in the
early years of infancy, it is generally styled post-natal atelectasis.
Pathology. The condition of collapse is found in circumscribed
patches, called lobular, or it is diffused throughout the greater portion
or whole of a lung. It occurs usually in the lobular form, the scattered
condensed portions then presenting a wedge-shape, the base being to-
wards the circumference. The lobules near the surfaces or margins of
the lungs are most apt to be involved. The state of collapse exhibits
very nearly the same appearance as that of the undeveloped foetal
lung. Although Legendre and Bailly have frequently been credited
with first describing this similarity, in 1844, it was in reality Jörg, a
German author, who first, in 1835, spoke of the return of a once ex-
panded lung to its fœtal condition without its undergoing an inflam-
matory process. Experiments demonstrating the expansibility of the
solid lung tissue have since been frequently made, adding very fair
proof to the correctness of the original statement. But Friedelben
asserts that these sections of airless tissue are due to imperforate
canaliculi of the respiratory vessels or bronchial tubes, a condition of
imperfect development which may last for years; he further declares
that it is an impossibility for a lung once expanded to resume its former
state.
Prior to the revelations made by Jörg, those condensed portions of
lung were always ascribed to lobular pneumonia. Pathologists had
observed the different appearance such lung tissue presents from that.
of hepatization, but they rested there.
The collapsed tissue varies in aspect according as it is examined
soon or late after the change has occurred. It presents, at first, some-
what of a dark-red or violet hue when some congestion is present, but
as the blood alters, loses color, lessens, and becomes firmer, the color
of the condensed tissue assumes a much paler tint. The divisions of
the lobules are often seen as whitish streaks through the condensed
tissue. Where neither catarrhal pneumonia nor other inflammatory
action has been set up, the collapsed air-cells are found to be inflated
to a considerable extent by blowing through the bronchus leading to
the affected lobules; it then looks like normal lung, taking a light-red
tint. There is a great tendency for the air-vesicles to adhere when they
have remained in contact for some time; when this condition exists,
inflation, of course, can be, at most, only partial. The vessels leading
to the portion of lung involved, from obstruction and loss of function
292
A SYSTEM OF MEDICINE.
ปี
contract and become obliterated, and the tubes which are distributed
to the same point usually have an obstructing plug in them. In prox-
imity to the collapsed cells some of the neighboring lobules become
more or less emphysematous.
The condensation of lung tissue by pressure, as, for instance, where
an accumulation of fluid in the pleural cavity expels the air from the
cells of the lungs, is the condition which Laennec called "carnification."
This solidification is complete as far as it advances, and does not
involve single lobules as it does in collapse progressing from within.
If the compression is not continued too long, the lung resumes its
former state of expansion; but if it is kept up, the tissue loses its
fleshy look, and becomes somewhat bloodless, tough and shrunken.
Causation. The most common of the exciting causes of pulmon-
ary collapse is the accumulation of some material in the bronchial
tubes hindering the free passage of air to the cells. It matters not
what this substance is, so long as it obstructs the tube to some extent,
for the same collapsed state has been induced in animals by the in-
troduction of a foreign body into the air-passage. The mechanism of
its production is that the plug is carried by the column of inspired air
against the orifice of a lesser bronchial tube, and no air is permitted to
enter the cells beyond. When expiration takes place, the plug shifts
sufficiently to allow the exit of a portion of the residual air of the part.
The tube is again closed on inspiration, and the same process is re-
peated until no air remains, and the vesicles are collapsed. It will,
very naturally, be inferred that bronchitis is the preexisting disease
most likely to develop atelectasis. Add to this the possibility of the
bronchial inflammation being secondary to whooping-cough, croup,
or measles, and the patient, consequently, being in a debilitated state
from sickness; or if there is feeble respiratory movement, from typhoid
conditions, and inability to expectorate the secretions; or if there is a
rickety dyscrasia under it all, with poor hygienic surroundings, and a
badly nourished patient, then there are more than sufficient causes to
bring about collapse of the lungs. When a tumor is sufficiently large
to press on a large bronchial tube, collapse of the whole lung may take
place, after a time, as the growth increases.
The causes of the lung becoming carnified are such conditions as
will produce compression of the lung from without. It may result,
then, from a deformed thorax, excessive pericardial effusion, aneu-
risms or tumors, or from abdominal growths and distension. But the
chief of the causes is the accumulation of fluid or gas within the pleural
sac or, sometimes, pleuritic adhesions.
Symptoms and Physical Signs.-These do not constitute a very
reliable group for determining the presence of atelectasis in the living.
It is only under favorable circumstances that sufficient of them will
be found in one individual to make out a clear case. When collapse
DISEASES OF THE RESPIRATORY ORGANS.
293
accom-
has taken place, there is marked difficulty in breathing, and this is
sudden in its development. With the strong effort to inspire air, Rees
says, the chest falls in, more or less, because of the non-expansion of
the lung. The signs of deficient aeration of the blood ensue,
panied by a feeble cough, and the patient becomes wasted and ex-
hausted. Dulness on percussion will be found in proportion to the
area of lung condensation beneath, and is absent when the collapsed
tissue is in small scattered points. Bronchial breathing is sometimes
heard, but it is not so tense as in pneumonia, and vocal fremitus may
be increased in localized spots.
The absence of vesicular murmur over a portion of the lung may
be replaced by a dry, crepitant rale or compression-rhonchus if the
patient is instructed to take a full inspiration. It will be heard only
at the end of inspiration, and will last during but a few breaths; then
all will be quiet again. The recession of the chest walls when they
should expand, and the inspiratory dyspnoea are, at times, the only
signs of collapsed lung to be adduced in infancy. The tissues may
remain in a state of collapse for a considerable period, and if pneumo-
nia has attacked the condensed portion the dulness is permanent.
Diagnosis. Both lobar pneumonia and pleurisy have dulness on
percussion, similar to that which is elicited in diffused collapse. But
they have each their special history of development and progress,
with definite signs and symptoms pertaining thereto, which will
differentiate them from atelectasis. The same may be said of phthisis.
A patient succumbing under pulmonary collapse, presenting progres-
sive wasting, is not unlike a consumptive in appearance. But the
physical signs of the two maladies are not at all in unison, and while
the one has its rise and fall of the thermometer from hectic fever, the
other is more apt to be found with a sub-normal temperature.
Prognosis. The termination of this affection by death is very
frequent in children, and if it is associated with any of the severe
inflammatory affections of early life it adds much to the mortality of
those diseases. Yet, if the collapse is not sufficient to threaten imme-
diate death, the natural strength of the patient, the hygienic surround-
ings, the care bestowed, and the remedies prescribed will have greatly
to do with the chances for recovery.
Treatment.—If suffocation seems imminent from suspected col-
lapse during the progress of an attack of bronchitis, assistance should
be rendered to the respiratory efforts as quickly as possible. Some-
times artificial respiration, a hot bath, or rubbing the chest thoroughly
with oil, may aid nature in the struggle. Stimulants may also be of
temporary use, but to secure the expulsion of the mucus causing the
threatening symptoms there is probably no remedy in our Materia
Medica that equals Tartar emetic. In the August number of the
North American Journal of Homeopathy, 1860, Dr. R. Ludlam relates a
294
A SYSTEM OF MEDICINE.
case presenting sudden and alarming symptoms of collapse of the air-
cells, following an attack of bronchitis, in a boy ten days old. After
trying other remedies, with little or no effect, a grain of Tartar emetic,
2d dec., was put in a third of a glass of water, and doses of it given at
short intervals. The result was almost instantaneous relief, and the
child recovered. Dr. L. expressed the belief that Antimonium tartari-
cum was practically and pathologically specific for post-natal collapse
of the air-cells.
To prevent this condition of collapse setting in, much care must be
exercised in the selection of the proper remedies during the progress
of a bronchial affection which may lead to it. These remedies belong
to the group for the treatment of capillary bronchitis, and consist
chiefly of: Aconite, Belladonna, Bryonia, Chamomilla, Chelidon., Hepar,
Ipecacuanha, Mercurius, Pulsatilla, Spongia, and Tartar emetic, according
to the stage of the disease and the symptoms peculiar to the case.
When the collapsed state is consequent on pressure from distension
of the pleural cavity, the ways and means requisite for the treatment.
of the pleuritic affection must be adopted before any hope can be en-
tertained of compressed pulmonary tissue resuming its normal condi-
tion and function.
In either case, not the least important element aiding in the care of
the patient, will be the success with which the strength of the patient
is sustained; thus the attention of the attendant to the hygiene of the
room, as well as of the patient, and the selection of simple but nour-
ishing food must not be lost sight of.
PULMONARY GANGRENE.
BY A. K. CRAWFORD, M.D.
Pulmonary gangrene has been simply mentioned as a possible out-
come of pneumonia, but it occurs also in consequence of pulmonary
hæmorrhages, infarctions, emboli of the bronchial artery, or even of
the pulmonary. Retention of decaying matters in bronchiectasis, the
pressure of a tumor, or the breathing of irritating gases may cause it;
and so may phthisis, cancer, pyæmia, septicæmia, insanity, typhus,
alcoholism, and epilepsy be producing agents. It is usually found to
be very limited in extent, and only occasionally does it involve a con-
siderable portion of a lobe. According to the amount of lung tissue
affected, it is called circumscribed or diffused. The circumscribed
variety is usually well defined in outline and does not exceed in size
a toy marble to a walnut. Diffuse pulmonary gangrene is more or
less extensive, and has no line of demarcation. The lung thus dis-
eased is moist, pulpy, greenish-black, or brownish and black, and
DISEASES OF THE RESPIRATORY ORGANS.
295
gives forth an extremely putrid odor. The discovery of this fetor in
the breath is an almost certain symptom of the presence of gangrene
of the lung, and the only other symptom of positive value is the ex-
pectoration of gangrenous matter containing fragments of lung tissue.
The patient is greatly depressed, runs into a typhoid state, and tends
towards collapse. There is additional danger in these cases of pleu-
risy, extensive bronchitis, peritonitis, abscesses, or severe diarrhoea
setting in and lessening the chances of recovery. Gangrene is a very
rare pulmonary affection, and terminates fatally in the large majority
of cases, thus always justifying a grave prognosis.
Treatment.—Much can be done to modify the characteristic
stench, even when the case is beyond hope of recovery. The inhala-
tion of antiseptic vapors and of the spirits of turpentine poured on
boiling water exerts a good influence. Condy's fluid in solution, as a
gargle, is also highly commended. The patient should be fed liber-
ally on easily digested food, added to stimulants of alcoholic or malt
liquors. Many of the antiseptics are used internally also; such as
phenic acid, the sulpho-carbolates, sulphites, chlorides of lime and of
soda, the chlorate of potash, and the hypochlorites. Dr. A. E. Small
recommends the internal administration of teaspoonful-doses of willow-
charcoal in water, repeated quite frequently. The homoeopathic reme-
dies in vogue for pulmonary gangrene are Carbo veg., Arsenicum,
Lachesis, Kreosote, Secale, Silicea, Camphor, and China.
SYPHILITIC DISEASES OF THE LUNGS.
BY W. B. TRITES, M.D.
That the lungs are liable to suffer from the baleful effects of
syphilis was known as early as the beginning of the eighteenth cen-
tury, but the careful study of the diseases thus derived, the symptoms
by which they may be recognized, together with their treatment, is of
very recent date. As a consequence, our knowledge is limited, and
much of it still a matter of dispute. That such diseases occur has
been proved conclusively both at the bedside and by the revelations
of the post-mortem examination.
Snitzler has stated that a bronchial or lung catarrh is not an uncom-
mon attendant upon the earlier skin manifestations of syphilis. The
great majority of observers differ from him, and teach that syphilitic
affections of the lungs are developed only during the tertiary stage.
The most usual period of development is from the fifth to the sixth
year after contagion. Sometimes they occur as late as the tenth or
fifteenth year, or as early as the latter part of the first year, but the
latter has been seen only in cases of most malignant character.
296
A SYSTEM OF MEDICINE.
Two forms of this disease have been recognized, an interstitial hy-
perplasia and circumscribed gumma.
Interstitial Hyperplasia. This is characterized by a rapid
cellular development, thickening the septa of the lung, and compress-
ing the alveoli. The change begins in the interlobular connective
tissue; small, spindle-shaped cells appear which quickly develop into
connective tissue and are early traversed by blood vessels. The vas-
cularity of this new tissue is a peculiarity, and will aid us in under-
standing the frequent occurrence of hæmoptysis during its course.
Laucereaux gave the name of syphilitic pneumonia to this form of
lung disease. This cellular infiltration takes place primarily about the
blood vessels and smaller bronchi, both of which may be blocked by
the hyperplastic process. A lung thus affected exhibits a smoother
surface than normal, is firmer to the touch, and heavier. Its color is
a grayish-red or yellow. When the disease is manifested in new-born
children, we have a form in which the lung has a whitish color, but
this is extremely rare in adults. The whole lung may be affected, but
usually the process is limited to a single lobe. As time goes on, this
hyperplastic material becomes converted into a tough, contracting,
fibrous tissue, which draws together the lobules of the lung, thus
deforming and even obliterating them.
Circumscribed Gumma.-In the early stage of this form of
syphilis the tissue changes are very similar to those described above,
only instead of a general cellular infiltration of the lung it is limited
to certain localities, especially in the neighborhood of small blood ves-
sels and bronchi. The hyperplasia is also less active, and results in
the production of gray or yellowish-gray, hard, well-defined masses,
varying in size from that of a hempseed to that of a walnut. They
are separated from the lung tissue by a fibrous envelope which con-
verts them into tumors or nodules. They are usually few in number,
rarely more than six or eight being found, and are often single, differ-
ing in this from tubercular infiltration. Gummata usually occur in
but one lung; any part of the organ may become the seat of the dis-
ease, though the apices are not commonly attacked. The circum-
scribed tumors thus developed eventually soften at their centres from
fatty degeneration, partial absorption occurs, followed by calcification
and shrinkage, leaving a hardened nodule imbedded in a fibrous mass
in the lung tissue. If such tumors occur near a bronchus they may dis-
charge their contents into it, and leave a cavity which afterward heals
by contraction and cicatrization.
Symptoms. What symptoms will a patient suffering from syph-
ilitic affections of the lungs exhibit? Unfortunately, the symptoma-
tology of these diseases is extremely limited and uncertain. During
life it is impossible to distinguish between the two forms. Snitzler
has called attention to a troublesome tickling in the throat as an early
DISEASES OF THE RESPIRATORY ORGANS.
297
symptom of importance, but experience has proven it to be of little
value, as a variety of laryngeal difficulties may have the same symp-
toms. In the early stage the dyspnoea is slight, and if a cough exists.
it will be infrequent and dry, or else attended with a very scanty
expectoration. Nor will physical signs aid us to any great extent,
they being as a rule absent or limited to weak respiration; later, after
contraction of the interstitial substance, or softening, has taken place,
the signs exhibited are very similar to those of phthisis. As the dis-
ease progresses, dyspnoea increases, though it seldom becomes severe,
the cough occurs in paroxysms, and the expectoration grows purulent,
and is often tinged with blood. Symptoms also appear which indi-
cate the serious nature of the disorder, such as debility, pallor and
emaciation, though these are all less marked in syphilitic lung diseases
than in phthisis. Should such cases go unrecognized, and hence be
deprived of proper treatment, hectic fever and night-sweats finally
develop, thus completing the resemblance between syphilitic lung
diseases and phthisis.
Fournier, who has carefully studied the effects of syphilis as ex-
hibited in the lung, has described three varieties of these affections.
1st. A latent form in which the lesions are circumscribed, produce
no symptoms, and hence are not detected until after death.
2d. In the second variety there is merely slight disturbance of respi-
ration without disorder of the general condition, the symptoms being
those of limited induration or of a cavity.
3d. The third is a severe form presenting all the symptoms of
phthisis.
The symptoms of syphilitic lung disease, it will be noticed, are far
from characteristic. In practice our great difficulty is to distinguish
between these troubles and tubercular phthisis, which they so much
resemble, but from which they widely differ in both treatment and
termination.
The points of difference as given by Frederick Robinson are as
follows:
1. The physique. The ordinary characteristics of phthisis are
wanting. The chest is well developed, and the body well nourished.
2. The absence of constitutional irritation of a severe character.
The thermometer rises but little above the normal standard. There
is freedom from night perspiration, diarrhoea, and irritating cough.
3. The dulness of percussion is less pronounced and less definable
in extent; it more frequently affects both apices,* and simultaneously.
4. The characteristics of tubercular sputa in the earliest stage are
* Robinson thinks the apices are especially liable to disease in syphilis, in this
differing from all other authors. Fournier makes the absence of dulness at the apex
a strong sign of syphilis, believing it to be developed most frequently in the middle
or lower lobe. An evidence of the unsettled character of the whole subject.
298
A SYSTEM OF MEDICINE."
wanting. The patient is pallid, complexion waxy, and his general
appearance indicative of cachexia. Auscultation reveals loud, harsh.
inspiration, with expiratory murmur of same character, or else tubular
breathing if the case is more advanced. Vocal resonance, more or
less distinct, is always present. The pulse is frequent, but not so
rapid as in phthisis. There may be no sputa, or else a little frothy
mucus is hawked up from the throat rather than expectorated.*
Besides these differences, we will be guided in our diagnosis by the
history of the patient; if he can recall an attack of syphilis it will
aid us materially. Fournier has called attention to the remarkable
tolerance which such patients develop, the disease continuing for a
long time, and yet the patient retaining both strength and flesh. This
is very different from phthisis, and will aid us in distinguishing be-
tween it and syphilitic hyperplasia or gumma of the lung.
The course of the disease is usually slow, and the prognosis favor-
able. Such cases often run two or three years before life is threat-
ened, and even in the most formidable cases a cure can be promised.
The treatment of syphilitic lung affections consists in placing the
patient under the best possible hygienic conditions, and feeding him
upon a nourishing diet. Cod-liver oil will be found of value here, as
in the nearly related disease, phthisis. The body should be bathed at
regular intervals, and clothed in warm comfortable garments. Inter-
nally the patient must receive the iodide of potassium, and it is won-
derful how rapidly improvement follows its use. Cases which have
seemed to be in the last stage of tubercular phthisis will rapidly im-
prove, the cough will cease, the night-sweats and hectic disappear, the
dull places in the lung clear up, and the breathing again become
natural. The dose should consist of from five to fifteen grains of the
salt administered three times a day. The following formula is recom-
mended by Ricord and others.
B. Potassii iodidi,
Syrupi cort. aurantii,
•
KNO
zi
3 vi
•
M.-Dose from a teaspoonful to a tablespoonful three times a day.
Lane thinks it an important point in the use of the iodide to avoid
large doses at the commencement; he favors doses of two, three, or
four grains, given thrice daily, and gradually increased until the
larger doses are reached. He thinks also that mercurial preparations
have but little value in the treatment of these conditions. Mercury
will be found beneficial in proportion to the sthenic character of the
morbid process to be treated, being useful when the general condition
tends in the direction of hyperemia and of vascular and nervous
excitement. It is injurious in the opposite condition of vascular
* Reginald Thompson, who, in the main, concurs with Robinson, says the sputum is
sometimes abundant.
DISEASES OF THE RESPIRATORY ORGANS.
299
depression, anæmia, and a general failure of power, and these are the
almost constant characteristics of tertiary lesions.
Homœopathic literature contains but little concerning the value of
the similar remedy in this class of disease. Jahr's work was written
when but little was known of the visceral ravages of syphilis. Yeld-
ham used the Iodide, while Berjeau, Morgan, and Franklin merely
refer to the subject. Hoyne mentions a case cured by Carbo vegeta-
bilis alone, and recommends as of value Nitric acid, Hepar, Silicea,
and Sulphur.
Helmuth has derived good effects from Kali bichrom., in the second
decimal trituration, given twice or thrice a day. Of the mercurials,
he prefers the bichloride. Arsenic, Iodum, Macrotys, and Podo-
phyllum have been given from time to time with benefit.
CANCER OF THE LUNG.
BY H. R. ARNDT, M.D.
Synonyms. Pulmonary cancer, Malignant disease of the lung.
Pathology. Pulmonary cancer is a disease of rare occurrence,
hence possesses comparatively little clinical interest. Childhood and
the period of adolescence are almost wholly exempt from it, but with
this exception, age has no marked bearing upon it. It is found more
frequently in men than in women, and almost always is unilateral.
Authorities differ concerning the greater liability of one lung over the
other to an invasion by cancer. It has been maintained, usually,
that the right lung more frequently becomes the seat of the disease;
J. Risdon Bennett states, however, that of thirty-nine cases tabulated
by him, "the left lung was the principal seat in fourteen, and the
right in nine only, whilst of the remainder, either both lungs were
affected, or the disease was confined to the mediastinum."
Pulmonary cancer rarely occurs as a primary disease; in fact,
eminent authorities hold that it is always a secondary affection. This
latter view is not tenable; yet, it is undoubtedly true that in an over-
whelming majority of cases cancer of the lung is secondary, occurring
particularly often after the full establishment of cancer in the testicle
(Walsche) and in the bony structure (Days).
Various forms of pulmonary cancer have been noted, of which the
medullary or encephaloid is of particular interest, because it occurs far
more frequently than all the other forms combined; the scirrhous ranks
next in frequency, though it is quite rare. Of the colloid only few
cases have been recorded, and they have usually occurred as a sequela
of a growth of the same nature in the mucous membrane of the ali-
mentary or biliary canals; this form consists of small spherical masses,
300
A SYSTEM OF MEDICINE.
composed of small transparent grains, which are surrounded by the
wall of an infundibulum.
The medullary cancer bears a striking resemblance to the brain,
and varies in consistency from a very soft to a tolerably firm mass.
The consistency of the tumor depends upon the density of the stroma,
a network of fibrous bundles which have undergone fatty degenera-
tion. An abundance of cancer-juice is readily obtained by squeezing
the cut surfaces; it is a creamy, thick fluid, freely supplied with cells
and free nuclei, fatty detritus, and free oil-globules. The cancerous
growth, especially in its early stage of development, is freely traversed.
by minute blood vessels, which give it a rather pinkish appearance;
the walls of these vessels are exceedingly delicate and easily ruptured.
When ruptured, the admixture of blood and blood-clots with the con-
tents proper of the tumor forms the fungus hæmatodes. The term
fungus melanodes refers to a dark-colored, blackish cancerous mass,
and its color is due to the presence of black coloring-matter in the
cancer-cell.
The primary cancer commences with nodules which enlarge, form-
ing one or more round masses, with a decided thickening of the cover-
ing pleura. "Upon cutting into the diseased parts, it is common to
observe whitish islands or granulations similar to those of the hepa-
tized lung, separated by pigmented septa of lung tissue. These islands
are due to the stuffing of an infundibulum by the carcinomatous
elements. In scraping the cut surface with a scalpel these granula-
tions are removed, and a milky fluid is obtained. A microscopic
examination of these sections shows the alveoli filled by large spher-
ical or polygonal cells containing large, usually oval, nuclei, with
distinct nucleoli. The alveolar walls are very frequently preserved
intact, or they may be somewhat thickened by the formation of small
round cells between their fibres. Their vessels are gorged with blood.
There is, therefore, no stroma of new formation in carcinoma of the
lung, but the fibrous trabeculæ are constituted by the altered inter-
alveolar septa." (Cornil and Ranvier, Manual of Pathological Histology,
p. 428.)
Secondary pulmonary cancer, depending upon the existence of the
disease in some other organ or structure of the body, is found accom-
panied with cancerous condition of the adjoining organs, pleura, bron-
chial tubes, heart, pericardium, diaphragm, blood vessels, and nerves;
these organs may become involved by the gradual extension of the
disease from the pulmonary structure, or they may have been affected
first, the disease later involving the lung. The connective tissue of
the lung is first affected; it becomes infiltrated and thickened, firmly
holding, and gradually encroaching upon, the bronchial tubes, usually
involving the latter throughout their entire thickness. Little disk-
like elevations appear scattered more or less thickly upon the mucous
DISEASES OF THE RESPIRATORY ORGANS.
301
surface, which eventually coalesce and form well-defined, slightly
elevated ridges, easily distinguished from the healthy structure, and
not infrequently alternating quite regularly with them. As the dis-
ease progresses, the integrity of the bronchial tubes is more or less
completely destroyed; the glandular structure becomes involved, the
mediastinal glands at times forming an enormously large cancerous
mass; the walls of the veins become affected, those of the arteries
usually resisting the action of the destructive process; both vessels,
however, not infrequently, are much compressed by the steadily en-
larging and encroaching tumor; the nerves also may become involved
in the degenerative changes, and Beigel (Reynolds's System of Medicine)
states that “the vagus and recurrentes are particularly liable to become
involved in the process, and to be materially altered." In the mean
time, inflammation of the parts leads to the firm adhesion of the dis-
eased lung to the inner surface of the sternum or of the ribs; or the
continuous growth of the tumor, practically replacing the normal
pulmonary structures, results in compression and atrophy of the in-
volved lung, with more or less extensive adhesions. The shape of the
diseased side of the thorax and the contour of the diseased lung not
infrequently remain unchanged; the healthy lung, however, being
called upon to perform double duty to compensate for the uselessness
of its mate, becomes enlarged, and the chest-wall of that side may
show considerable fulness.
Secondary pulmonary cancer is multiple. Very numerous small
bodies, no larger than a millet-seed, may be scattered throughout the
diseased lung, or a smaller number of tumors, frequently attaining
remarkable proportions and a weight of many pounds, may be found.
These tumors, while still of moderate size, are round and clearly
defined; as they assume large proportions they lose their clearness
of outline, in part by a process of "blending," but more particularly
from hæmorrhages resulting within them, and from adhesive inflam-
mation. Occasionally, distinct and firm cancerous tumors originate
in the lung substance, and, enlarging centrifugally, eventually burst
through the pleura.
Cancerous growths of the lung, like similar tumors in other portions
of the body, undergo rapid degenerative changes. They soften from
the centre to the periphery, forming either cancerous ulcers or cavi-
ties which contain a foul, bloody, puriform substance; the walls of
these cavities are thickened and, like their contents, in a state of dis-
integration. Sloughing away of masses of the diseased structure,
though not of frequent occurrence, may take place.
Semeiology.-The symptoms of pulmonary cancer vary in clear-
ness with the conditions surrounding the case, their character and
that of the concomitant symptoms depending largely upon the struc-
tures implicated. Quite often the absence of diagnostic symptoms is
302
A SYSTEM OF MEDICINE.
remarkable, especially in cases in which the affection in the lung is
secondary to more advanced disease in other parts of the organism.
It must also be borne in mind that small malignant growths may exist.
for a considerable length of time and not give rise to distinctive physi-
cal signs, nor to sufficiently marked constitutional symptoms to afford
room for a reliable diagnosis; this absence of physical signs is easily.
understood when we remember that these small growths are surrounded
by normal lung tissue, giving normal sounds upon auscultation and
percussion.
Nearly all sufferers from pulmonary cancer are more or less annoyed
by cough, which in some cases is dry, tearing, and hacking, while in
others it reaches considerable violence, and is barking or ringing, or
even resembles whooping-cough. The character of the cough depends.
to a considerable extent upon the degree of bronchial or pleural affec-
tion, and even a very persistent and tormenting laryngeal cough may
result from implication of the vagi. If the former complications are
extensive, and, as is often the case, effusion has taken place, the patient
suffers more or less, and often very severely, from the symptoms fol-
lowing effusion into the pleural cavity, among which inability to lie.
on the well side and distressing shortness of breath deserve especial
mention.
The expectoration accompanying the cough may be insignificant in
amount or even wholly absent. Usually, however, and almost always
when the morbid action involves a considerable area, the expectora-
tion is muco-purulent, contains admixture of blood, and the micro-
scope shows the presence of cancerous tissue. A very fetid odor of
the expectoration proves the existence of a cavity in the lung com-
municating with a bronchus, in which case detritus of lung-tissue is
likely to be found present in the expectoration. If sloughing of the
lung-tissue has taken place, large, putrid, gangrenous masses are
coughed up. If there occurs destruction of the walls of a large blood-
vessel, copious, and perchance fatal, hæmorrhage from the lungs is the
result; the blood, owing to the peculiar exemption of the arteries from
destruction by the cancerous process, is almost always venous.
The development of these symptoms is not accompanied by much
pain or fever. Pain may not be experienced to any great extent even
in severe cases; when it is present, it is the result of compression of,
and pressure upon, a nerve, and extends along the course of the
affected nerve, even to parts far removed from the seat of pressure.
The fever is usually of a low grade and partakes of the hectic; neither
pulse nor temperature rises high, but distinct exacerbations are likely
to occur in the evening, with an increase of the pulse more marked
than that of the temperature, and followed by copious and very ex-
hausting sweating.
Auscultation and percussion do not yield physical signs of
DISEASES OF THE RESPIRATORY ORGANS.
303
diagnostic value. Small hard masses in the lungs are not readily de-
tected, but if the solid tumor is of considerable size, we have dulness
on percussion, and fail to get the normal respiratory murmur over the
affected part. The presence of large pus-cavities or the existence of
extensive miliary deposits is recognizable by the proper sounds.-The
external chest, in well-established cases, will be found to differ from
the normal both in form and in facility of movement. If much pres-
sure from within outward is made by a very large tumor or by a very
copious effusion into the pleural cavity, the thorax presents a bulg-
ing, enlarged appearance; if much atrophy exists, or extensive adhe-
sions have formed between the costal and pulmonary pleura, the chest
appears depressed and flattened. The full movement of the chest-
walls is embarrassed by adhesions and compression of the normal
lung-tissue from the presence of fluid or air.
Various conditions combine to affect the heart. The extension, by
contiguity of tissue, of the morbid action to the pericardium and to
the heart itself; the pressure upon the heart by a large foreign mass
within the chest; extensive effusion in the chest-cavity and pressure
upon the heart, or displacement of this organ resulting therefrom;
closure of the bronchial tubes by filling up with cancerous masses;
the disturbances necessarily arising when a lung is sufficiently diseased
to cease the performance of its important duty,-all these directly lead
to a disturbed action of the heart which is likely to cause much dis-
comfort to the patient. Two other conditions contribute to the same
end: pressure upon some terminal fibre of the vagus, caught in the
meshes of the tumor, and atrophy of the heart itself, which may occur
as a part of that general atrophy which results from cancer.-Dyspnea
is one of the most distressing symptoms found in pulmonary cancer.
It is largely the result of the disturbed action of the heart, but may
depend upon pressure upon a fibre of the vagus, and even, to a certain
extent, upon a lack of elasticity in the lung-tissue which is occasioned
by the free distribution and the effect of abundant miliary deposits
throughout the lung. Pressure upon the recurrent nerves and, in
some cases, paralysis of the laryngeal muscles from pressure upon
the controlling nerves, lead to an impairment and, later, to a complete.
loss of voice. The power of deglutition is affected by swelling of the
cesophagus and by compression of the organ, resulting in dysphagia,
probably necessitating the use of the stomach-pump for purposes of
feeding.
The general appearance of the patient, after the morbid process has
become established, is not unlike that of a person well advanced in
consumption. An attentive study of the symptoms described shows
the really considerable similarity which exists between the two con-
ditions; even the hectic fever, night-sweats, emaciation, and colliqua-
tive diarrhoea are found alike present in both conditions. In ma-
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A SYSTEM OF MEDICINE.
lignant disease of the lung, however, we find evidences of the cancerous
cachexia which are wholly wanting in phthisis.
Several symptoms are found in all intrathoracic tumors, hence occur
also in pulmonary cancer. To these belong a marked contraction of
one or both pupils of the eye, and a light-yellow, limpid effusion into
the pleural cavity, often very copious and containing albumen; this
effusion refills rapidly if removed by trocar or aspirator.
The progress of this disease is accompanied by the gradual loss of
appetite and sleep, an anxious state of the mind, considerable and,
usually, rapid emaciation, languor, physical debility, an enlarging of
the superficial veins, and, finally, dropsy of the lower extremities.
Diagnosis. The diagnosis of primary cancer of the lung, even if
far advanced, resolves itself into a mere suspicion of its existence,
suggested by the presence of a group of symptoms difficult of explana-
tion upon any other hypothesis; in the earlier stages of the primary
form, its recognition is practically impossible.
The diagnosis of secondary pulmonary cancer in the earlier stages
is still surrounded by many difficulties. We must depend chiefly
upon the existence of cancerous growths in other parts of the body,
and upon the appearance of lung-symptoms after the removal of a
cancerous growth. The gradual or sudden diminution of the amount
of air admitted into the lung, as shown by the spirometer, or the ap-
pearance of symptoms which betray the cancerous habit, with the
evidence of the microscope, showing the existence of cancer-elements
in the sputa, would place a positive diagnosis within reach.
In differentiating pulmonary cancer from other morbid conditions,
it is of the utmost importance to make a thorough study of the his-
tory of the case, and it will be found that the constitutional and con-
comitant symptoms will, in a majority of cases, prove much more
valuable than the physical signs.
The close resemblance between pulmonary consumption and pulmon-
ary cancer has already been pointed out. It is to be remembered that,
outside of the symptoms already pointed out, cancer is rather more
limited in the extent of the area involved, is more likely to be one-
sided, and gives rise to a variety of symptoms which have been de-
scribed as resulting from pressure upon neighboring organs or nerves,
such as palpitation of the heart, dysphagia, loss of voice, etc. In pul-
monary consumption, on the other hand, the territory involved is
larger, the bleeding is of much more frequent occurrence, the sputum
shows the characteristics of tubercular disease, and there is an absence
of symptoms indicating the cancerous cachexia. A symptom which
deserves far more emphasis than is usually placed upon it is the
peculiar hopefulness of the consumptive which confidently looks for
eventual recovery in spite of the most alarming symptoms, in contra-
distinction to the anxious, and even despairing, state of mind of the
DISEASES OF THE RESPIRATORY ORGANS.
305
patient suffering from cancer. The two affections may, in exceptional
cases, coexist, in which case a differential diagnosis is out of ques-
tion.
It may become necessary to determine whether an existing effusion
into the pleural cavity depends upon pulmonary cancer or upon a
bronchitis. Here, again, the history of the patient, and the expression
of an existing cachexia, as shown by the constitutional and concom-
itant symptoms, form our chief reliance. In addition, it is to be
remembered that the effusion of bronchitis gives rise to an area of
dulness which changes as the position of the effusion itself, in obedi-
ence to the law of gravitation, changes with every change in the posi-
tion of the patient; it has also been pointed out by writers on this
subject, that in the latter condition the effusion may diminish con-
siderably, and with it, the area of dulness on percussion, after profuse
sweating or copious diuresis.
The pathognomonic signs of aneurism are usually well pronounced,
but a possibility exists of mistaking this condition for pulmonary
cancer at the root of the lung, producing a decided prominence in the
clavicular region. In addition to the general indications of the can-
cerous habit, it is well to bear in mind that the pulsation in cancer
of this form must necessarily be diffuse, while in aneurism it is cir-
cumscribed.
Prognosis and Treatment.-The prognosis is absolutely hopeless.
The disease always terminates fatally, death, in the majority of cases,
occurring in from one to two years after the disease was recognized.
The treatment is practically limited to the relief of the suffering of
the patient, to the careful watch over symptoms which are likely to
arise from complications, and which the homoeopathic remedy is very
likely to control in a measure, to well-chosen regimen, and, eventually,
to the judicious use of narcotics when imperatively demanded by the
condition of the patient and our inability to furnish relief by other
and more satisfactory means.
If the patient suffers from bronchial, pleuritic, and other complica-
tions, we meet the symptoms by the exhibition of remedies, homœo-
pathically, which are known to act curatively in such conditions; for
instruction on this point, the chapters on bronchial affections, pleuri-
tis, etc., must be consulted.
Dyspnoea constitutes one of the most frequent and tormenting con-
comitants of cancer of the lung. In attempting to control it, the
physician must recognize the causative condition, whether it be effu-
sion, pressure upon nerve-fibres, or muscular weakness; but even then
he is confronted, almost always, with the absolute impossibility of
reaching the cause. Relief may be afforded by the use of counter-
irritants, particularly small blisters, dry-cupping, or by the perform-
ance of paracentesis. Frequently, the relief from tapping is of very
VOL. I.-20
306
A SYSTEM OF MEDICINE.
short duration; yet, this relief is so marked that the operation is not
impracticable in spite of the rapid filling-in of the effusion.
Inhalations containing chlorine, carbolic acid, creasote, perchloride
of iron, or Declat's phenic acid, remove, to a great extent, the horrible
fetor of the breath proceeding from such patients.
The use of morphine, chloral-hydrate, and anodynes generally,
becomes a necessity sooner or later. Morphine is preferable to all
others. Its use is to be put off as long as possible; when this can be
done no longer, the drug should be given hypodermically, and in very
light doses, increasing the dose only as imperatively demanded by the
increasing suffering of the patient.
The diet of the patient should be nourishing and easily digested.
Dysphagia existing, the use of the stomach pump may become a
necessity. Quiet, moderate exercise, judicious bathing, the best hygi-
enic surroundings obtainable, all these make up the sum total of treat-
ment.
In Germany, considerable confidence is placed by the profession
and by the laity on the value of the "grape-cure," in persons of a
suspicious family-history who give evidence of incipient cancer. At
Bingen on the Rhine, in Germany, and at Presburg, Hungary, exten-
sive arrangements exist, particularly during the season of the vintage,
for affording all necessary conveniences to persons who desire to avail.
themselves of this treatment.
It is almost useless to point out remedies suggested directly by the
existence of the cancer itself, and to give indications for their use.
Arsenicum album, Arsenic. iodatum, Conium, Aurum, Hydratis, Silicea,
Nitric acid, Thuja, and others, are presumed to exert upon such a con-
dition modifying and, perhaps, positively curative effects. In select-
ing the remedy, other things being even, particular importance should
be attached to the character of pain felt, to the mental symptoms, and
to the so-called modalities.
ASTHMA,
BY A. K. CRAWFORD, M.D.
Synonyms.-Latin, Asthma; French, Asthme; German, Eng-
brüstigkeit; Italian, Asma, Bolsaggine; Spanish, Asma.
Definition.—A neurosis, exhibiting itself in paroxysms of difficult
breathing, attended with wheezing, a constrictive sense across the chest,
a cough, and probably some frothy expectoration. The paroxysm is
due to the narrowing of the lesser bronchi by means of spasm of their
circular muscular fibres. The term has been applied to many different
forms of dyspnoea, and is still employed in all cases presenting the
above characteristics, without reference to their source.
DISEASES OF THE RESPIRATORY ORGANS.
307
Varieties.-Nervous or spasmodic asthma is the form to which so-
called nervous individuals are disposed, and its defining character is
that there is no trace of any diseased condition when the attack ceases.
This kind of asthma is referred to as emotional. It is the asthma which
hysterical women have; a paroxysm of it may be precipitated by
mental excitement, or it may occur in either sex when there is no evi-
dence of hysteria, nor any known excitant. Opium eaters, too, are
subject to it if their usual dose has not been taken.
Common or Catarrhal Asthma may be subdivided clinically into
those spasms which are associated with acute, or with chronic, catarrhal
affections. The peculiar feature of this variety is the constant irrita-
tive, congestive, or inflamed condition of the bronchial mucous mem-
brane, and, in addition to the paroxysm noticed in the nervous variety,
there is apt to be more or less habitual dyspnoea.
Hay Asthma furnishes a good example of the variety which occurs
with an acute catarrh, although it oftentimes does not develop the
kind or degree of spasm necessary to constitute a real asthma. Hay
fever or hay asthma is a summer catarrhal affection, which occasions
severe coryza, sneezing, cough, and difficult breathing, with much red-
ness of the membrane of the eyes and nose. It occurs in individuals
having a peculiarly sensitive mucous membrane, and in whom it may
have been noticed, previously, that the inhalation of dust, of pungent
odors, or of powdered ipecacuanha, would induce symptoms of acute
catarrh. Whether some such substance may not be the immediate
cause of an attack of hay asthma, or whether it is provoked by inflores-
cent particles emanating from the rag-weed or other plant, or whether
it is caused by some imponderable specific poison, is not definitely
known. But we do know that it recurs annually, that having had it
once renders the subject liable to it each successive year, that it is an
exceedingly exasperating affection, and that it stubbornly resists the
influence of remedies. A similar condition of the bronchial mucous
membrane, not confined to a season, but continuous and chronic in its
nature, and accompanied by asthmatic attacks, was termed by Laennec:
Latant Catarrhal Asthma.-There does not appear to be any
change in the physical condition of the mucous membrane, but it
evidences the same irritability that is found in acute catarrhal states,
and its tendency is to degenerate into some form of chronic catarrh.
This form is the one most common in childhood. The children who
have it are short-winded, and playing with their companions will
induce dyspnoic attacks. They take cold readily, and while the cold
runs its course, the asthma and dyspnoea are augmented. They are
subject to nightly exacerbations and daily remissions. With each
successive cold the attacks of asthma increase in severity and duration,
until it has arrived at the point of being a well-pronounced mucous
catarrhal asthma.
308
A SYSTEM OF MEDICINE.
Humid Asthma.-Asthma of the aged, or mucous catarrhal
asthma, is the variety which begins with an acute catarrh. But when
the fever has disappeared, the cough and expectoration persist. The
dyspnoea which accompanies this condition is sudden in its onset,
regular in its paroxysms, returns at night, and is worse in damp and
cold weather.
Millar's Asthma is an old-fashioned term used to denote an acute
form of asthma, either of a congestive or catarrhal nature. Even out-
side of its production by heart disease, sudden and extensive conges-
tion of the bronchial membrane sometimes occurs, with distress in
breathing. To this, as well as to cases of suffocative catarrh, and false
and spasmodic croup, the name Millar's asthma was frequently ap-
plied; but these different affections are now treated of under the re-
spective headings to which they belong, and the author's name has
been omitted from the nosology of asthma.
Some
Clinical History. The paroxysms of dyspnoea in asthma, which
constitute the chief feature of the complaint, are also found to recur
periodically in many cases. They differ much in their severity and
duration, as well as in the intervals between their recurrence.
cases show the greatest irregularity in the return of the attacks, while
others have them diurnally, weekly, fortnightly, monthly, or yearly,
with the precision of planetary revolutions. Salter says that those
who are subjected to diurnal paroxysms, have, usually, either bron-
chitis or disease of the heart; and it is not unfrequent that women
suffer with asthma only at the monthly nisus.
As would be inferred from looking over the varieties of asthma,
there must be wide differences among them during the interval of the
attacks. The phases which present themselves at such time, will de-
pend greatly on the character and degree of progress of the associated.
complaint. Emphysema is present during the paroxysm in probably
every case of asthma. In many, it is but temporary, abating with the
subsidence of the attack, and, consequently, these patients do not
suffer from it afterwards. But the majority of patients exhibit signs
of its continuance, and complain, therefore, of shortness of breath, or
dyspnoea, in the interval. In those who, when free from asthmatic
attacks, still have a cough and expectoration, chronic bronchitis is as-
sociated with the asthma. Heart complications sometimes coexist
with asthma, enlargement and valvular impairment being the ordi-
nary changes noted. The result of this is that circulatory disturb-
ances occur, and the degree of dyspnoea is proportionally affected.
Bronchitis and asthma are very intimately associated, and many of
the asthmatic attacks are attended by a renewal of the bronchial af-
fection; but sight must not be lost of the fact that bronchitis is of
every-day occurrence without asthma, and that asthma sets in fre-
quently unaccompanied by even a trace of the bronchial affection.
DISEASES OF THE RESPIRATORY ORGANS.
309
The one is a mucous inflammation, the other an occult neurotic dis-
ease, so that they are distinct maladies, and not dependent the one
upon the other.
Asthma attacks only a small proportion of the human race, but it
is not limited to any particular age, the infant, the robust adult and
the aged are alike liable to suffer from it. The relative number of
cases increases from twenty up to fifty years of age, and Salter says
about eighty per cent. of the whole number are males. The gouty
diathesis is often seen to run parallel with the inherited tendency to
asthma; especially in the case of women who are subject to asthma,
a family history of gout is frequently clearly defined.
Causation. It seems to be the general belief that heredity is a
most potent and frequent predisponent of asthma, and that it is a
constitutional disease. By far the greater number of persons who
suffer from asthma, can point to its previous existence among their
progenitors. But this alone is not sufficient to account for a large
share of the cases found. Some condition, acting as an excitant, seems
to be requisite to start asthma into existence. The causes which pre-
cipitate the attack are very numerous, and, in fact, appear to vary
somewhat with each individual case. The inhalation of grain-dust,
of sulphur-fumes, indigestion, constipation, mental emotions, the ap-
pearance of the menses, fatigue, physical exertion, meteorological dis-
turbances, sudden changes in temperature, storms, mists, snow, a sup-
pressed eruption, gastric irritation from sweetmeats, highly seasoned
foods, the unaccustomed or the careless use of fermented liquors, etc.,
are all accredited with acting, under favorable conditions, as causative
agents.
Symptoms and Physical Signs.-The prodromal symptoms of
an attack of asthma are vague, and often wanting. Some patients are
able, by means of some one indefinite sensation, or the appearance of
some peculiar symptom, to predict, with certainty, the occurrence of
an attack on the following night. Among these premonitory symp-
toms mention may be made of a slight headache, mental excitation,
or depression and drowsiness, a slight feeling of oppression of the
chest, flatulence after a meal, or indications of a little feverishness.
These may last throughout the day, grow more marked as night comes
on, and not until the patient is sound asleep does the attack set in.
It is noticed that, in some cases, no previous symptoms occur; but
the paroxysm develops suddenly and augments rapidly. In others,
the onset is gradual, and several hours may be occupied before it at-
tains to its height.
A premonitory sign observed by Salter, and one frequently met, is
an itching sensation under the chin. The same peculiar, creeping,
tickling sensation often extends down the sternum, and is felt between
the shoulders.
310
nœa.
A SYSTEM OF MEDICINE.
It is in the black hours that the asthmatic attack usually occurs.
The patient is suddenly awakened from a sound sleep with a sensa-
tion of suffocation, and immediately finds that he has violent dysp-
The erect posture, leaning forward, is chosen and retained
throughout the paroxysm, and, with the head thrown backward, he fixes
himself in that position by grasping and firmly holding a chair-back
or mantelpiece. At the same time, the dilated eyes, the expanded
nostrils, the open mouth, the blueish pallor of the face, the profuse
perspiration, the look of extreme suffering, and the coldness of the ex-
tremities, all these give clear evidence of the intensity of the paroxysm,
and of the distress of the patient. Respirations are often less numerous
than in health, and each occupies a greater period of time than the
normal. The inspiration is short and gasping; the expiration very
much prolonged and wheezing; therefore the dyspnoea is expiratory
in rhythm.
Sometimes a profuse flow of clear urine, like that passed in hysterical
attacks, precedes the paroxysm a day or two, but usually it is not
observed until the dyspnoea is developed. The patient cannot lie
down nor stay in bed, but must be up, with doors and windows open,
regardless of the temperature outside. This undue exposure for hours.
during the night to a chilling atmosphere, as is frequently the case,
does not seem to affect the patient unpleasantly, while the fresh, cold
air certainly gives temporary relief.
Ordinarily, the pulse is small, feeble, and sometimes intermittent,
and, with the coldness of the surface, it is not very rare to see œdema
of the lower extremities, which disappears with the attack.
Sometimes the commencement of the attack is marked by vomiting,
and it may possibly continue while the dyspnoea lasts. The appetite
is poor, the digestion slow, and, consequently, the patient is apt to be
drowsy after eating.
During the attack a cough appears, even when it did not exist be-
fore. It is harsh and dry until the paroxysm lessens, when a profuse
expectoration occurs which gives relief to the patient. The voice is
hoarse and veiled, and a tracheal wheezing sound accompanying
respiration can frequently be heard at some distance from the suf-
ferer.
Complaint is made of certain painful spots about the chest, which,
during the first attacks of asthma, are wandering and ill-defined, but
later they become more constant and intense. They are considered
to be pleuritic in character. Besides this there is often a sense of
painful constriction at the base of the chest.
The expectoration is sometimes streaked with blood, or a regular
hæmoptysis may be witnessed during the occurrence of the increase
of the other symptoms. Sometimes the hæmorrhage appears inde-
pendent of any general exacerbation, after the manner of its occur-
DISEASES OF THE RESPIRATORY ORGANS.
311
rence in phthisis. If its significance is misinterpreted, grave errors
in prognosis may be made.
The remission of the paroxysm may be as sudden or as slow as its
onset. It may not take place for several days, but usually the morn-.
ing brings a great abatement, probably a total disappearance of the
attack, with restful, peaceful sleep.
With the increase of the frequency and severity of bronchial inflam-
mations, with the advance of emphysema, with the lessened intervals
between the attacks of asthma, and the augmented force of the latter,
very serious disorders of the circulatory apparatus develop, which in-
crease the growing dyspnoea. The heart is found to beat irregularly;
it is enlarged, and there is frequent palpitation. Edema, previously
noted, now progresses to anasarca, and ascitic accumulation ensues.
These symptoms are usually referred to valvular lesions of the heart,
but they can exist without such cardiac trouble, and are more prop-
erly the result of asthma itself and the lung-changes which accom-
pany it.
The Physical Signs of a paroxysm of asthma are not many. In-
spection tells of a chest that is held rigid at its utmost expansion. It
is increased in size in every direction. The diaphragm is lowered,
and the measurement around the body is increased. The shoulders
are elevated, the back is rounded, and the neck is held stiff. While
intense effort is being made to accomplish respiration, but little chest
movement is observable. The upper portion is especially immobile,
the lower alone giving any sign of action. Percussion gives an aug-
mented resonance, particularly in the front regions of the chest, but
it is not always equal on both sides. Throughout both lungs loud
sibilant and sonorous rales are heard, as well as rattling of mucus and
wheezing. There is no vascular murmur on account of the complete
stagnation of air in the lungs. This extreme distension sometimes.
causes an air-cell to burst, and the presence of this extravasated air in
the lung tissue is evidenced by a rubbing sound. The dry rales, ema-
nating from the constriction of the smaller tubes, are constantly
shifting, and are heard loudest over the posterior portions of the chest.
The respiration itself is characterized by a short spasmodic or jerking
inspiration, and a prolonged noisy expiration, the relative time occu-
pied by the two acts being the reverse of that common to physiological
respiration. As the attack subsides, a general exaggerated respiration
is heard to precede the return to normal breathing.
Diagnosis.-Dyspnoea occurs to quite an extent in several differ-
ent conditions of the system which necessarily present more or less
similarity to asthma. Of these, two have received the name of asthma,
viz.: cardiac asthma and renal asthma. If a patient suffering from the
cardiac form has an exacerbation of breathlessness at night, it will
usually be relieved by assuming the erect posture for a time, but such
312
A SYSTEM OF MEDICINE.
a patient is never entirely free from oppressions of the chest. No
wheezing is heard as in asthma, and there will be found physical
signs of heart trouble, if looked for. Renal asthma is accompanied
by much distress in breathing, not because the air cannot reach the
blood circulating in the lungs, but because the blood is prevented from
reaching the air in the cells on account of the spasm of the pulmonary
arterioles. A rapid pulse will direct the attention to the heart, but find-
ing no trouble there, symptoms of changes in renal texture must be
immediately sought for. When children have capillary bronchitis,
they experience much difficulty in respiration, and often labor ex-
ceedingly hard, but they breathe more frequently than in asthma;
the pulse is accelerated, and the sub-crepitant rales are present in
both lungs. In diseased conditions of the glottis and larynx, such as
oedema, spasm, and paralysis, the locality of the distress referred to
by the patient is very different, and the absence of chest symptoms.
and wheezing will aid in distinguishing them from asthma. Dia-
phragmatic trouble, whether rheumatic, paralytic, or of the nature of
fatty degeneration, occasions severe dyspnoea. Respiration is carried.
on mostly by the superior part of the thorax; and, with the loss of
power in this muscle, there is inability to aid in the performance of
the act of urinating and of defecating. When a forced inspiration is
taken, the epigastric and hypochondriac regions sink, and distend.
again with each expiration. If the diaphragm is paretic, Duchene
says, galvanizing the phrenics will start it to proper action, and the
abdominal movements will then be the reverse of what has just been
stated. Da Costa speaks of a case of glandular swelling of the neck,
coming on suddenly, and pressing on the trachea to such a degree
that, with the attending difficulty in breathing and wheezing noise,
the patient's complaint might readily have been mistaken for asthma.
Pressure from tumors in the mediastinal space causes similar symp-
toms, but the dyspnoea is continuous with them.
But we are not likely to confound a case of spasmodic asthma with
any other affection if we keep in mind its pronounced paroxysmal
character, its suddenness of onset, its rapidly developed and extreme
dyspnoea, its limited duration, its comparative or complete freedom
from harassing symptoms during the interval, and the physical signs.
of temporary bronchial spasm, with its constant accompaniment―
wheezing.
Prognosis. An old saw has it that "asthma is a charter of a long
life," but if so, longevity must be held in high esteem to be bought at
such a price. It is true, death during an attack of asthma is rarely
recorded, but the continuance of the affection by developing emphy-
sema, dilatation of the heart, and dropsy, must necessarily tend to
shorten life.
If humid asthma once fairly lays hold of a person advanced in
DISEASES OF THE RESPIRATORY ORGANS.
313
years, it persists without interruption until it has terminated the pa-
tient's life. But if a youth, attacked with the ordinary form, has it in
a modified way, with long intervals of relief, and without organic dis-
ease of any kind, the prognosis is favorable. If a patient's strength
has been impaired by reason of repeated and severe attacks of asthma,
and he should then have pneumonia or severe bronchitis, the chances
for recovery will be very limited. But asthmatic subjects are usually
spared from both pneumonia and pulmonary tuberculosis.
Treatment.—If an attack of asthma has been provoked by any
known condition, such as an undigested meal, or a constipated state
of the bowels, this condition should be righted as speedily as possible.
Dyspepsia is so commonly met with among asthmatics that their diet
requires careful selection. They should, of course, eat regularly and
moderately. Sloppy food, malt liquors, sweet pastry, and fats should
be avoided; and the regimen must be confined mostly to beef, mut-
ton, chicken, or eggs, with stale bread and boiled rice. A little coffee
may be allowed at breakfast, and either whisky and water, sherry, or
toast-water later in the day, if deemed advisable. Care should be
taken to avoid much fluid for a time both before and after meals, and
the same injunction should be put on mental or bodily exercise,
especially for an hour after eating.
The remedies for asthma must be considered in regard to their
adaptability to the spasm and to the interval. Resort will be had to
various methods and substances by the patient himself, in order to
relieve the severity of the attack, and if anything has been found by
experience to afford any relief in former fits, it is best to acquiesce in
its continuance. Some of the more common of these adjuvants to
internal medication are the smoking of Stramonium, the breathing of
Nitrate of potash fumes, or the inhalation of Chloroform, Ether, or
Amyl nitrite; but while these often give temporary relief, they never
cut short an attack.
The old school strongly recommend, at present, the use of Jaborandi
or its alkaloid, Pilocarpin. It is claimed that a hypodermic injection
of ten minims of a 2 per cent. solution of the latter, secures almost
immediate relief to the patient in a paroxysm.
Remedies for the Attack.-The chief remedies are: Aconite,
Arsenicum, Bryonia, Ipecacuanha, Lobelia, Sambucus, Cuprum, and Hydro-
cyanic acid.
Aconite.—When the accession of the attack has been induced by cold, dry air,
or subjection to a foggy atmosphere.
Arsenicum.-For nightly paroxysms, with great restlessness and anxiety, and
burning pains in the chest. There is perspiration of the whole body, with alternate
hot and cold sensations, and prostration.
Bryonia.—In addition to the symptoms of the spasm, there is some bronchitis,
and sharp pains around the chest, much worse by deep inspiration and by motion.
Ipecacuanha.-Is the remedy used most frequently, and is recommended by
314
A SYSTEM OF MEDICINE.
all schools. The dyspnoea is very considerable, there is constriction of the throat and
chest. The cough is constant, with rattling of mucus, nausea, and vomiting. The
surface is cold and damp, and the face pale. The remedy is given when there is no
immediate assignable cause for the attack.
Lobelia.—Is indicated for a paroxysm induced by gastric trouble. There is
immense development of gas in the stomach, and little or no cough. The attack is
often preceded by a prickling sensation all over.
Sambucus.-Is of service when the degree of dyspnoea is beyond that wit-
nessed under Ipecacuanha, and the cough is less. The patient evidences extreme
anxiety, the face becomes violet in hue, and asphyxia seems imminent. Loud sibilant
rales accompany the dyspnoea. Sambucus is usually employed in the tincture.
Cuprum.-Is especially useful in the purely nervous variety of asthma. Its
onset is sudden, the respiration is very spasmodic, is complicated with cramps and
convulsive twitchings, and terminates suddenly. The attack may occur in conjunction
with the menstrual epoch, or in consequence of emotional excitement.
Hydrocyanic acid.-Is recommended by Hughes for the class of cases which
suggest Cuprum. He uses it in recent and uncomplicated asthma, when there is diffi-
cult and spasmodic respiration, with contraction of the throat, and feelings of suffo-
cation.
Remedies for the Interval.-Arsenicum, Nux vomica, Sulphur,
Pulsatilla, Tartar emetic, Iodine, and Aurum.
Arsenicum.-When this remedy is called into requisition for the paroxysm,
it is frequently found to relieve also the habitual, wheezy, dyspnoeic state. The indi-
cations are præcordial anxiety, with exacerbations at night; cough, accompanied by
the expectoration of a transparent, frothy, viscid fluid. When chronic bronchitis,
emphysema, or cardiac disease complicates the case, Arsenic is often of service. It is
also to be kept prominently in mind when the asthma is a neurosis, probably alter-
nating with some other nervous disorder, as well as when it depends on a repercussed
eruption.
Nux vomica. For irritable persons who are accustomed to drinking coffee or
liquor. After the subsidence of an attack the tongue exhibits a thick yellow coating.
There is a feeling of fulness in the stomach, with belching, and constipation. As Dr.
Russell says of it, there remains a sort of physical memory of the struggle, and the
patient feels that no liberties must be taken, either of diet or exercise. If the attack
began with sneezing and fluent coryza, or if vapors of copper or arsenic started it, or
if it is merely spasmodic, in consequence of a hypersensitive pneumogastric, Nux and
Strychnia are most useful remedies. At times, both Nux and Arsenicum are pre-
scribed in chronic cases, the first-named at night, the other in the morning.
Sulphur.—This remedy stands well in the treatment of asthma when skin affec-
tions alternate with the dyspnoea, but it is even a more powerful agent against the
complication of the asthmatic with the gouty constitution. The attack is marked by
sibilant dyspnoea, bluish lips, and it recurs once a week, usually in the night.
Pulsatilla.—For a case of asthma ill-defined in its onset; with an abundant
catarrhal expectoration, vertigo, vomiting, prostration, and palpitation of the heart.
It may have been due to deranged menstruation, hysteria, uræmic poisoning, or a sup-
pressed rash.
Tartar emetic.-Has also great abundance of secretions, with rattling of
mucus, and difficult expiration. It is specially recommended for old people and young
children.
Iodine. In the form of the Potassium iodide this remedy is in much favor
among some old-school practitioners, and Bæhr points out its well-marked homœo.
pathicity by its effects when taken for a protracted period. The attack usually occurs
about midnight, lasts half an hour, and is succeeded by lassitude and an irresistible
desire to sleep. The patient is nervous and restless during the interval, and the
asthma appears to be entirely of the spasmodic variety.
Aurum.-For morning asthma, with bluish face and great palpitation of the
heart; suffocative attacks, with spasmodic constriction of the chest. The accompany-
ing symptoms are of involvement of the heart and pulmonary congestion.
DISEASES OF THE RESPIRATORY ORGANS.
315
Other useful remedies in the treatment of asthma are:
Belladonna.-When the attack comes on in the afternoon or evening, with
congestion of the face and head; worse in hot, damp weather.
Cannabis.-Is of use only in massive doses, and after thus using it once, may
prove to be entirely ineffective in subsequent attacks. Its action is narcotic, and
hence palliative. Given in the first attenuation it is said to be serviceable in humid
asthma.
Chamomilla. For children during dentition, and often for hysteric asthma,
especially if induced by anger, and accompanied with flatulence.
Carbo veg.-For old and feeble people whose attacks come on after midnight,
so severe that they seem to be dying. There is distension with wind and inability to
raise it.
Digitaline.—For a purely nervous asthma, without accompanying lesions of the
lungs, heart, or bronchi. The paroxysms are frequent and of comparatively short
duration. Digitalis is a palliative even when right ventricle dilatation coexists. The
attack is preceded by palpitations, and there is marked venous congestion of the head
during the spasm, followed by violent headache. It is also useful in men debilitated
by sexual excesses.
Kali bich. is recommended in "humid asthma," when the signs of mucus in the
bronchial tubes far exceed the amount actually present. The gastric mucous mem-
brane is simultaneously affected.
Moschus. For asthma in people of a nervous, irritable, or hypochondriac dis-
position. There is a violent feeling of constriction in the throat, without cough.
Opium, or Morphine, in a low attenuation, will often give great relief with-
out inducing narcotism. The respirations are slow and labored, the face is cyanotic,
the sensorium depressed, and cough constant.
Pulmo vulpis.-Von Grauvogl used a first centesimal trituration of this
remedy as a remedy in an old subject suffering with asthma humidum, and met with
brilliant success.
Sanguinaria is recommended in hay asthma and in post-climacteric asthma.
In the latter instance Dr. Ludlam gives it upon the following indications: severe
dyspnoea, teasing, hacking cough, dryness in the throat, and an inclination to take a
deep inspiration during the paroxysm.
Spongia has rendered some service in asthma due to phthisis, by mitigating the
severity of the attacks. The spasm is marked by complete loss of voice, wheezing
respiration, and contraction of the glottis.
Stannum, Plumbum, Zincum, Ferrum, Argentum have all been accorded
a place among the remedies for asthma, but their indications are not
always well defined, nor are they clinically proved to be reliable.
The following remedies may be consulted, as possibly indicated:
Apis, Asafœtida, Bovista, Bromium, Calcarea carb., Causticum, Cistus can.,
Cocculus, Colchicum, Gelsemium, Graphites, Grindelia, Hepar, Hypericum,
Kali carb., Lachesis, Lactuca vir., Lycopodium, Mephitis, Natrum sulph.,
Nitric acid, Nux moschata, Phosphorus, Sabadilla, Salicylic acid, Sepia,
Silicea, Staphysagria, Sticta, Thuja, Veratrum.
316
A SYSTEM OF MEDICINE.
E. DISEASES OF THE PLEURA.
PLEURODYNIA.
BY A. K. CRAWFORD, M.D.
Pleurodynia or "false pleurisy" is a myalgia, or a rheumatic con-
dition of the chest-walls, analogous to torticollis and to lumbago. It
is unattended with fever, and with but little general disturbance of
the system. The pain is oftentimes located in the left infra-mammary
region, but there appears to be no tendency to involvement of the heart.
The causative agents are those which are common to rheumatism else-
where, such as: exposure to draughts, or to cold and wet weather. It
is more often found in adults, and more frequently in men than in
women. A gouty constitution may be considered a predisponent, and
a previous attack of the disorder tends towards its recurrence.
The muscles subject to the attack are either the pectorals, inter-
costals, or the interdigitations of the serratus magnus with the external
oblique.
The pain complained of is extreme, and is aggravated by every
motion. Consequently, the side affected is held passive, and the act
of respiration is thereby impeded. The patient shrinks from cough-
ing or sneezing on account of the increase of pain which these acts
occasion. When localized, the pain is often catching in character, and
direct pressure on the spot makes it worse. Sometimes the broad
pressure of the palm of the hand affords some relief. Both sides are
frequently affected simultaneously, and the pain is quite apt to shift
its position.
However much it may seem to resemble pleurisy, none of the physi-
cal signs of the latter affection ever appear in pleurodynia. It is
differentiated from intercostal neuralgia by the greater area of pain.
presented, by its alternating with other myalgias, and by the absence
of the painful points which belong to the neuralgic condition.
Treatment. -The list of remedies for this complaint might be
lengthened indefinitely, but the following will be found particularly
reliable:
Aconite is recommended to be given frequently and in a low dilution if there
has been exposure to a cold, dry wind, and when some fever is noted.
Arnica when there is a bruised sensation. The pain is increased by motion, but
still more by pressure. The patient complains of the bed being too hard. When
there are doubts as to whether the pains indicate pleurisy or pleurodynia, Arnica will
often clear up the case by curing it.
Actæa racemosa, or its alkaloid Macrotin, is especially adapted to women,
when the pains resemble neuralgia, when there are menstrual disorders, and when
there is a sense of faintness at the pit of the stomach.
Bryonia.—The pains are stitching and tearing. They are aggravated by move-
DISEASES OF THE RESPIRATORY ORGANS.
317
ment, and diminished by broad pressure and by lying on the affected side. It is
especially useful in the rheumatic diathesis.
Colchicum.-In a combination of the gouty and rheumatic constitution; when
acute attacks spring up, with palpitation of the heart, chilliness even when near a
hot stove, and gastric disturbance. The pains are shifting, burning, or jerking in
character.
Nux vom. For hæmorrhoidal subjects and habitual drinkers. The patient
cannot lie on the painful side.
Ranunculus bulbosus.-Hughes claims wonderful success with this remedy
in pleurodynia, when the pain is so intense that the patient dare not move. Left-
sided infra-mammary pain.
PLEURISY.
BY A. K. CRAWFORD, M.D.
Synonyms. Inflammation of the pleura; from the Greek alsupĪTIS;
Latin, Pleuritis; French, Pleurésie; German, Pleuritis, Rippenfellen
Entzündung; Italian, Pleuritide; Spanish, Pleuresia.
Definition. Inflammation of the serous membrane which covers
the lungs, and which is reflected over the costal walls internally. The
attack is marked by chilliness and fever, and is followed by knife-like
pains in one or both sides of the chest. The lubricant which nor-
mally moistens the pleural surfaces, disappears at first. Afterwards,
there is a greatly increased quantity of fluid exuded, and the chest
wall distends proportionately. Accompanying these changes, there
will be a dry cough, rapid, uneven, and shallow respiration, and a
quick tense pulse.
Pathology.—In the chapter on pneumonia, the conclusion was
arrived at that it was the pulmonary vessels alone which were in-
volved in that affection. And now, in so far as the pulmonary pleura
is concerned, it is known to be the bronchial vessels which are impli-
cated in this inflammation, because of the anatomical fact that the
subdivisions of the bronchial arteries ramify the sub-pleural tissue,
and give sustenance to that membrane.
At times, pleurisy is described under the qualifying heads of tho-
racic, mediastinal, or diaphragmatic. This is merely an anatomical
consideration, depending upon the locality of the inflamed surface,
and not upon any difference in the character of the process.
Of much more practical use is the division of pleuritis into the acute,
sub-acute, and chronic forms. By acute pleurisy is meant the inflam-
mation which continues through the plastic exudative stage, but which
only develops a slight amount of effusion. The sub-acute variety is
that in which the effused serum is considerable, and easily determina-
ble by physical exploration. The chronic is that in which absorption
of the effusion does not take place. When this stationary fluid be-
comes purulent in character, it is ordinarily designated empyema.
True empyema refers to an accumulation of pus or of sero-puru-
318
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A SYSTEM OF MEDICINE.
lent matter in the pleural cavity, arising directly from the pleural
surfaces, and is thus distinguished from false empyema, which derives
its pus from a ruptured pulmonary abscess. Pus, in this situation,
must find an exit, or the patient will decline under hectic fever. If
there is a sufficient quantity to have compressed the lung, so that that
avenue of escape is cut off, the confined pus will likely point in an in-
terspace between two ribs, and discharge itself in this way. This
purulent degeneration of the effused pleural fluids generally occurs.
in connection with the exanthematous and puerperal fevers, pyæmia,
or from perforation.
The progress of the disease is marked by three stages, viz.; hyper-
æmia, effusion, and absorption. There is no clear dividing line be-
tween their occurrence, but each has its well-defined signs, and the
terms are self-explanatory. The stage of hyperæmia is regarded as
extending from the onset of the attack until the occurrence of an
appreciable amount of exudation, which usually takes place within
twenty-four hours. Then the stage of effusion is fairly at hand, and
it is still counted such while the accumulation grows and while this
remains stationary at its height. The time occupied in this process
is sometimes quite short, the fluid being found to diminish in quan-
tity immediately following its effusion. The third stage is marked by
the physical signs of constant decrease of the amount of fluid in the
pleural cavity. The time taken to absorb all the effusion is more va-
riable than the preceding stage. Convalescence may be thoroughly
established, and still part of the fluid remains unabsorbed. But, as a
rule, an attack of pleurisy runs its course in from two to three weeks.
If, at the end of this time, the fluid effused shows no disposition to
disappear, the disease is pronounced chronic, and the fluid tends to
become more or less purulent in character.
In the first stage of the inflammation, the pleura presents a dry,
roughened, and reddened appearance. The sub-serous tissue shows a
greatly increased degree of vascularity, and spots of ecchymosis are
not uncommon. The advent of the second stage is marked by the effu-
sion of fluid into the pleural cavity. This fluid is generally serous at
first, mixed with lymph-shreds, which float through it, or which settle
when the liquid is quiescent. The effusion is sometimes purulent
from the first, but as a rule, the pus, liquor, and cells, are a later de-
velopment. In the second stage, the surface of the lung is coated over
with a slimy plastic material, and the lung itself is forced upward and
backward by the accumulated fluid. This pressure also forces the air
out of a greater or less amount of lung tissue, and condenses it, so that
it presents a flesh-like appearance when cut, to which the term " car-
nified" has been applied. The anatomical changes incident to the
third stage, or that of absorption, are more marked if the effusion has
been of long standing. It is then we may find portions of the lung
DISEASES OF THE RESPIRATORY ORGANS
319
still in a state of carnification, and so bound down by firm fibrous
bands that it never returns to its normal condition, and is ever after
impeded in its action. When such is the case, the chest wall becomes
retracted, especially over the area of lost respiratory function and of
adhesions. This altered chest wall again causes a lateral curvature of
the dorsal spine towards the affected side, and a compensatory curve
in the opposite direction in the lumbar vertebræ.
Clinical History.-Pleurisy is so frequently associated with pul-
monary consumption, and is consequently so often linked with tuber-
culosis or some other constitutional cachetic state, that its onset in any
given instance demands the closest scrutiny of the physician to deter-
mine its source and its significance. It is not nearly so tractable an
inflammation as pneumonia, for while the latter has extensive exuda-
tions during its progress, its tendency is toward entire resorption and
a return of the involved lung tissue to perfectly normal function. But
with pleurisy it is very different. It tends toward the production of
morbid products, of adhesions of new tissues, and entails, therefore,
more permanent mischief.
Pleurisy is generally unilateral. The idiopathic variety of it is dif-
fused, involving the whole or the greater part of one pleura. When
the inflammation is circumscribed and sub-acute, the inference is that
it is secondary to some other pulmonary trouble. Should both sides.
show symptoms of limited inflammatory action, the evidence is still
greater that the pleurisy is merely symptomatic.
The fever may abate at the end of a week, and again start up after
a time, adding more fluid to that already effused. This may repeat
itself, and extend the duration of the disease over a period of some
months, possibly until the patient is carried off with the trouble.
Other cases present themselves, suffering from debility and shortness
of breath, who give no history of the acute symptoms of pleurisy, but
who are found with all the signs of advanced effusion present. This
insidious and slowly developing form of the malady was named latent
pleurisy by Laennec, and Niemeyer says that such cases generally
terminate in pulmonary phthisis. Chronic pleurisy may continue in-
definitely without the fluid becoming purulent, while some cases of
either the acute or sub-acute variety rapidly develop suppuration.
Where this occurs, the patient evidences it by the relief from pain, a
rapid, compressible pulse, great anxiety and restlessness, and an evi-
dent tendency to collapse.
Causation. The causes of pleurisy are not so easily determined as
in many other acute affections. It is nearly always a secondary
malady, occurring in connection with, or superadded to, some other
morbid state. It may be spontaneous in its origin, and its source be
beyond our ken, or it may be the result of cold and exposure; the
latter is the least common of its causes. Injuries, either to the outer
320
A SYSTEM OF MEDICINE.
chest-wall or piercing the cavity of the chest, will, oftentimes, set up
pleuritis, but in army surgery, extensive lacerations of the pleural
membrane have been witnessed, without inflammation following. It
does frequently occur in patients suffering with Bright's disease, and
happens in the course of acute articular rheumatism, as well as in the
different zymotic, and typhoid, and typhus fevers. It adds itself to
the history of pyæmia and septicemia, and attacks gouty subjects. It
may be said to be a concomitant in every case of phthisis pulmonalis ;
and, like the other serous surfaces in the body, when it is the seat of
tubercular deposit, flashes of inflammation are constantly recurring.
It frequently complicates cases of pneumonic inflammation, but in
practice it is not met with so often as the lung-affection.
Symptoms and Signs.-The onset of pleurisy is marked by some
degree of chilliness, often repeated, but seldom severe enough to be
pronounced a chill. The fever following is not of a high grade. A
dry irritating cough sets in, which greatly aggravates the sharp darting
pain in the chest, or "stitch in the side." The latter is the most char-
acteristic and constant symptom of the first, or dry, stage of pleurisy.
This pain is increased by any movement made by the patient. It is
for this reason that the sufferer employs abdominal respiration, breathes
very shallow and rapid, and holds the ill side as passive as possible.
There is usually some degree of tenderness of the thorax on pressure,
and the patient lies on the well side.
The physical signs accompanying this stage are a diminished respi-
ratory movement observable over the affected side; to the touch will
be conveyed that peculiar thrill termed friction fremitus; to the ear,
the vesicular murmur will sound feeble and jerking, and possibly a
to-and-fro friction-sound may be heard.
The progress of the disease into the stage of effusion is noted by the
disappearance of the pain and the abatement of the fever, but the cough
still continues, and dyspnoea develops in proportion to the amount of
serum effused. The patient now turns not on, but only toward, the
affected side, and the complexion is apt to become dusky. The physi
cal signs, in this instance, are characteristic. In looking at the chest.
it will be seen that movement has almost, if not entirely, disappeared,
and the side appears more than ordinarily full. The intercostal spaces
are level with the ribs, or even bulge beyond them. The vocal vibra-
tions are absent. The area extending from the base of the chest to
the level of the liquid in the pleural cavity will be found flat on per-
cussion, but above that water-line we have increased resonance. This
flatness is changeable according to the position assumed by the patient.
Lying on the back may leave the whole anterior aspect of the chest
clear, while the reverse will be the case if the patient lies on the face.
Two conditions may occur in which the shifting percussion sounds.
will not be found. One is where the exuded material is of such a con-
DISEASES OF THE RESPIRATORY ORGANS.
321
sistence, and exists in so limited a quantity that it will not gravitate.
The other is where former adhesions hold the fluid in circumscribed
sacs, thus confining it and preventing its change of locality. The
heart is often very much displaced by means of the distension of the
pleural cavity of either one side or the other, and as the diaphragm
sinks with the pressure from above, so do the liver and stomach become
displaced downwards to the same degree. The ear can discover no
breath murmur where effusion is present to any great extent. Bron-
chial breathing may be detected in the inter-scapular space near the
spine. The normal voice-sounds fail to be transmitted, and are either
absent or very feeble. No friction sound is to be heard. The well lung,
or the healthy portions of the inflamed side, take on puerile respiration
because of the extra work required.
The stage of absorption runs parallel with the gradual disappearance
of the symptoms of the second stage, and with the return to health.
The cough and dyspnoea subside, the temporarily displaced viscera
return to their normal locations, and the patient is able to turn on
either side without discomfort. Inspection and palpation make known
the fact that the respiratory movements are re-appearing, and that vocal
fremitus is again perceptible. The percussion dulness, in the erect pos-
ture, is found to diminish from above downward, until it entirely dis-
appears. As the chest movements increase, the vesicular murmur, at
first very weak and indistinct, becomes quite harsh and pronounced,
followed later by normal breathing. During this period of harsh res-
piratory murmur bronchophony is to be heard, which gives way to
exaggerated, then to normal, vocal resonance. The pleure, which
have been separated in consequence of the effusion, on coming to-
gether again reproduce the friction sounds incident to the first stage
of the disease.
These signs and symptoms pertain to both the acute and sub-acute
varieties of pleuritis. The difference between the two resting entirely
on the intensity and extent of the development of the malady, it is
but a relative matter naming a case one or the other. But when an
instance of the sub-acute form of pleurisy is met with, and the effusion.
completely fills the cavity of the chest, with its signs of distension, en-
largement, immobility, percussion flatness, and absent murmur, the
apex of the same side may emit a tympanitic percussion note, and, by
auscultation, bronchophony and bronchial breathing will be heard in
the same locality. Where this occurs it is not uncommon to find
bronchial respiratory sounds transmitted all over the diseased side.
The reasons for the first condition may be plain enough, for the last
probably not quite so tangible.
A perfectly normal condition is not to be looked for on the sub-
sidence of an attack of pleurisy. The most ordinary of the permanent
changes, appreciable by physical examination, is a retraction of the
VOL. I.-21
322
A SYSTEM OF MEDICINE.
chest-wall over the base of the lung, some dulness on percussion,
especially at the back beneath the scapula, and a correspondingly
diminished respiration. This is the result of fibrinous adhesions and
an excessive amount of plastic material not absorbed, or of a portion
of condensed lung failing to unfold itself.
""
The physical signs attendant upon empyema, or the chronic form of
pleuritis, are just such as belong to a well-developed case of the sub-
acute variety. There is less likelihood in empyema to find a change
in percussion dulness following a change of posture, because of the
adhesions that are so common with the development of pus. Some-
times the cardiac impulse is transmitted through the purulent accu-
mulation, and gives rise to the question of its being a case of thoracic
aneurism. These cases have been called "pulsating empyemata.'
The presence of pus in the pleural cavity is of such moment that the
knowledge of it should be in the possession of the medical attendant
at the earliest possible moment. The development of symptoms of
hectic fever, with night-sweats, remissions of the fever in the morning,
and exacerbations in the evening, a puffy appearance of the face, the
ends of the fingers assuming a club-shape, and, maybe, a trace of
purulent matter in the sputa, will point, almost positively, to the fact
of pus being confined in the chest. But if a doubt still remains, the
hypodermic needle will settle the question.
Diagnosis. The affections with which the dry stage of pleurisy
is apt to be confounded are pleurodynia and intercostal neuralgia.
In neither of these do we find fever or friction sound, and the pain of
pleurodynia or myalgia is found frequently to shift its locality. It
also usually involves both sides, and the chest is very tender and sen-
sitive to external pressure. Intercostal neuralgia is most often left-
sided, choosing preferably the nerves from the sixth to the ninth ribs.
The pain is markedly intermittent in character, and anæmic indi-
viduals or women with pelvic disorders are its most common subjects.
It is often diagnosticated by discovering the three painful points of
Valleix. Over the track of the involved nerve a sensitive spot will be
found at its exit from the spinal column, another in the line of the
axilla at the angle of the rib, and a third over the terminal distribu-
tion of the nerve near the sternum.
During the stage of effusion, pleurisy bears some resemblance to
acute pneumonia. Both are characterized by fever, pain, dyspnoea,
by usually involving only one side, and by presenting dulness on
percussion. But here the similarity ends, for the absence of the respi-
ratory murmur, and of the vocal sounds and vibrations, in pleurisy,
stand in wide contrast with the intense thrill, the bronchophony, and
the loud tubular breathing met with in pneumonia. And no matter
to what extent pneumonic consolidation may go, there is no bulging
of the side, as in pleurisy.
DISEASES OF THE RESPIRATORY ORGANS.
323
If tubercular infiltration should suggest itself, it may be differen-
tiated from pleurisy by the development of dulness and the other signs
from above downward, and if the tuberculosis has advanced to any de-
gree, the opposite lung will likely be involved. An enlarged liver or
spleen may so press upward as to encroach on the base of either lung,
and give percussion dulness over normal lung area. But by listening
posteriorly, the respiratory murmur will generally be detected, and a
deep inspiration will increase the extent over which it can be heard.
For the distinguishing signs between pleurisy and hydrothorax and
pneumothorax, the reader is referred to the separate discussion of
these topics.
Prognosis.—The natural tendency of simple uncomplicated pleu-
risy is to recovery. But if there is any chronic affection of the lungs,
if the effusion is great, or if the patient has not had careful treatment,
the result may be the reverse. In fact, the termination of pleurisy
depends upon the gravity of the disease with which it may be com-
plicated. Even in idiopathic pleurisy deaths have been recorded by
apnoea from excessive effusion. In the chronic varieties the same
thing may occur, although such cases are rare. When pleurisy is
associated with Bright's disease of the kidneys, or other morbid con-
ditions, it is apt to run a chronic course, and to terminate fatally by
asthenia. Its coexistence with pericarditis greatly increases the gravity
of the prognosis, and when complicated with tuberculosis, the super-
vention of a fatal issue is only a matter of time. Yet, if the presence
of plastic adhesions is certain evidence of inflammation of the pleura,
many persons make good recoveries unwittingly, for the post-mortem
table makes it appear quite a common affection among those who
experienced none of the symptoms of the disease.
Treatment. In the acute stage of pleurisy, when the lancinating
pains are very severe, much benefit can be derived from the applica-
tion over the side implicated of hot fomentations, hot linseed poultices,
steamed hops, or mustard paste. But if after some hours the desired
effect has not been produced by this means, securing immobility of
the side affected by strapping it with adhesive plaster from the spine
to the sternum, after the manner recommended by Roberts in his
Handbook of Medicine, will afford relief.
In the effusive stage, even when the distension is very considerable,
so long as life is not threatened by reason of the pressure obstructing
respiration, the contents of the pleural sac should be let severely
alone. But in case the patient suffering with chronic or empyemic.
pleurisy shows signs of depressed vitality, anxious and hurried respi-
ration, weakened pulse, and livid countenance, the operation of para-
centesis thoracis should be resorted to at once. In case the fluid to
be thus removed is serous in character, the utmost precaution should.
be exercised to prevent the entrance of air into the pleural cavity,
324
A SYSTEM OF MEDICINE.
else the bland serous fluid will readily become purulent. The best
mode of accomplishing this operation with safety is, probably, with
the pneumatic aspirator. It is a procedure very generally adopted,
since Dr. Bowditch has shown how the dangers attending it may be
avoided. He advises that the needle be inserted behind, in a line
running perpendicular from the angle of the scapula, and two inches
above the normal base line of the lung. Nor is it necessary to drain
the cavity completely, for the removal of only a part of the fluid often
stimulates the process of absorption sufficiently to secure the comple-
tion of the task by nature's method. Of course, where it is known.
that the accumulation consists of pus, the same care is unnecessary.
After aspirating once, and obtaining pus, it is better, when the second
evacuation is required, to make a free incision through an intercostal
space, and to empty through a double drainage-tube. The tube should
be left in situ and secured; then the pleural cavity can be irrigated
each day with a solution of carbolic or salicylic acid, or of iodine, or
with Condy's fluid.
In all cases where such depletion is going on, the patient should be
fed rather liberally, and often some stimulant is required, not only to
enable the patient to bear drain on the system, but in order that the
process of absorption may become more active and perfect. The
amount of liquid taken with the food should be restricted.
Aconite. Simple acute pleurisy caused by exposure to cold, with the symptoms
of chill, fever, stitch-like pain in the sides, dry cough, anxiety, restlessness, tossing
about, and inability to lie on the right side. It not infrequently cuts the attack short
in the first stage.
Bryonia. Follows Aconite well when the disease is advancing through its
regular stages. It is also the choice remedy when the disease begins with a low degree
of violence, and shows early signs of effusion. It is specially useful in the secondary
form of pleurisy of the plastic variety, and circumscribed in extent. The severe
stitching pains are aggravated by every motion, the tongue is white, there is thirst for
large quantities of water, and often the patient finds relief from lying on the affected
side.
Cantharides.-The indications for the use of this drug in pleurisy have been
furnished by E. Farvie, and its practical application to the disease in question is ex-
tolled beyond all else by Jousset. He uses it in the 3d dilution usually, but if this
does not produce rapid amelioration he descends to the 2d or 1st dilution, or even to
the mother tincture. Its special symptoms are: a profuse serous exudation, dyspnœa,
cough, and palpitations of the heart; a tendency to syncope, with heavy sweats and
scanty urine.
Arsenicum.-Is to be given when there is great prostration and threatening
collapse. The effusion is copious and rapid. It is well indicated for those patients
who are weak and cachectic, malarial, or who are addicted to alcohol. An excellent
remedy in empyema.
Sulphur.—Is said to follow well after Bryonia or Rhus tox, when absorption of
the plastic material is slow. The pain is steady, left-sided, and in the lower portion
of the chest, extending through to the shoulder-blade. Rheumatism or gout accom-
panies the pleuritic attack. The lips are bright red.
Senega. Should be given in subacute or chronic pleuritis, when complicated
with heart disease or phthisis, and when there is a marked tendency to anasarca.
Apis mel.—Is indicated when there is great dyspnoea; the patient is unable to
lie down, and feels as though he could not draw another breath. The urine is scanty.
DISEASES OF THE RESPIRATORY ORGANS.
325
Jousset has employed it with excellent effect when Cantharides failed to produce
absorption.
Arnica. The pleurisy is the result of traumatism. There is a bruised feeling
in the chest, as well as over the body generally. Nervous patients with cool extremi-
ties and hot head.
Asclepias tuberosa.-Very acute pain in the right chest; labored breathing,
especially marked at the base of the left lung; dry and spasmodic cough.
Belladonna.-In pleurisy coexistent with the exanthematic, typhoid, or puer-
peral fevers. In plethoric or tuberculous subjects, with delirium.
Carbo veg.-When the fluid has assumed a purulent or ichorous character.
Hectic fever, with sunken countenance, wasting, and prostration.
Colchicum.-Red and scanty urine, containing albumen. Gouty constitution,
and sour-smelling perspiration which affords no relief.
Digitalis.-Wurmb, Fleischmann, and Baehr all recommend this remedy for
pleurisy with abundant serous effusion. The last-named author says it ranks next to
Bryonia for rheumatic pleuritis.
Hepar sulph.-When pleurisy has become chronic, and the exudation has been
transformed into pus, this remedy, with Arsenicum and Silicea, is of marked value.
There are intermittent paroxysms of hectic fever. The face assumes a yellowish-brown
tint. In scrofulous and lymphatic individuals.
Iodum should be kept in mind as a possible help to Sulphur in securing ab-
sorption of a serous, or more particularly of a plastic, exudation.
Kali carb.-The violent and stitching character of the pains peculiar to this
remedy point to its use in pleurisy. It is strongly indicated when the left side is
affected, with heart palpitations, and aggravation of a dry cough about 3 A.M.
Mercurius is indicated when the secretion tends from the first to become puru-
lent. There are frequent chilly sensations, followed by burning heat, and copious
sweats, which do not relieve. This remedy has rendered good service in epidemic
pleurisy, and also when syphilis, rheumatism, bronchitis, gastric or intestinal catarrh,
or icterus, complicate the malady.
Phosphorus.-When there is a sense of constriction across the chest, with a
dry, tight cough, worse in the evening, accompanying the pleural inflammation.
When the heart or kidneys are implicated, and empyema occurs, it is a valuable
remedy.
Rhus tox. may be given when the attack follows exposure to wet, or a strain,
in the presence of the usual accompanying symptoms of restlessness, hydroa about the
lips, and a red tip to the tongue. But Rhus seems better adapted to peritonitis under
similar circumstances, than to pleuritis.
Occasionally, one or more of the following remedies may be called
for in pleurisy, when a constitutional state or some specific symptoms
appear in the case to indicate them: Calcarea carb., China, Ferrum,
Helleborus, Kali hydriod., Kreasotum, Lachesis, Laurocerasus, Lycopodium,
Nitric acid, Nux, Sabadilla, Sepia, Spigelia, Squilla, Tartar emetic.
HYDROTHORAX.
BY A. K. CRAWFORD, M.D.
This condition of dropsy of the pleura, or "water on the chest," is
common to several diseased states, and is a purely secondary affection.
It consists of an exudation of limpid, watery fluid within the pleural
cavity. The amount of liquid varies from a few ounces to eight or
nine pints, and it lacks the fibrinous quality of pleuritic effusions.
326
A SYSTEM OF MEDICINE.
In hydrothorax there is no change in the epithelium of the pleura,
and there are no false membranes or plastic adhesions formed.
Other dropsies precede and coexist with it. It is habitually a two-
sided affection. The diseases in which it is produced are those which
involve the lungs, the heart, the great vessels, the liver, the kidneys,
or possibly the pleura itself; and not unfrequently a constitutional
or cachectic state of the system gives rise to it. The production of the
fluid is generally the direct result of mechanical obstruction of the
circulation, and of the abnormal thinness of the blood through defi-
ciency of albumen. The physical signs are the same as those of chro-
nic pleurisy. Sometimes the development of the fluid is so slow that
the respiration is not perceptibly disturbed by it. But when its onset
is sudden, and the amount very great, orthopnoea and its attendant
symptoms will be witnessed. To differentiate it from the effusion of
pleuritis, it will be necessary to bear in mind the lack of febrile move-
ment in its history, its simultaneous double development, its advent
after the appearance of dropsies elsewhere, the absence of pleuritic
pains and friction sounds, and the presence of organic visceral
disease.
Hydrothorax must be looked upon as a condition of extreme gravity,
and one which usually proves fatal. It sometimes appears just prior
to the fatal issue of the maladies named.
Treatment.-The best remedies for this lesion are such as prove
serviceable in anasarca, viz.: Arsenicum, Apis, Apocynum, Carbo
veg., China, Digitalis, Iodum, Jaborandi, Lycopodium, Mercurius,
Phosphorus, Sulphur, Tartar emetic.
PNEUMOTHORAX.
BY A. K. CRAWFORD, M.D.
This lesion is characterized by the presence of air or gas in the
cavity of the pleura. In the majority of instances in which this con-
dition is found, it arises from ulcerative perforation of the pulmonary
pleura extending from a tuberculous cavern. The remaining lesser
number of cases of gaseous distension of the chest come from: trauma-
tism, a penetrating wound, a fractured rib, or through the operation
for the relief of empyema; rupture of an emphysematous vesicle or
of a pulmonary abscess; a channel communicating with the œsopha-
gus or a bronchus; gas generating spontaneously in empyema or gan-
grene of the pleura.
Its onset is usually quite sudden, and is marked by excessive dys-
pnoea. The patient exhibits great mental anxiety, the countenance
assumes a pale and dusky hue, both the voice and the pulse are weak,
and a cold moisture covers the skin. The chest, or rather one side of
DISEASES OF THE RESPIRATORY ORGANS.
327
it, presents a full and distended appearance, the interspaces of the
ribs are either effaced or bulging, there is exaggerated percussion
resonance, indistinct or absent vesicular murmur, lost vocal fremitus,
and sometimes the amphoric voice and metallic sounds are heard by
auscultation and percussion. The advent of air within the pleura is
attended with excessive pain, indicative of the inflammation which is
at once set up in this membrane. The result is that in the course of
a few hours, usually, the pleuritis has exuded fluid into the cavity
already containing air, and to this combined and complicated condi-
tion the name of:
Hydro-pneumothorax has been given. Now a new set of signs
are developed from the union of pneumothorax with pleuritic effusion.
The tympanitic percussion resonance is still present over the upper
portion of the chest, but below, absolute dulness is found. A sense of
fluctuation is perceived by both the patient and the physician when
the chest is shaken, and if the ear is placed on it at the same time, a
gurgling, splashing noise is heard, described by Hippocrates as the
succussion sound, and which is distinctive of this disease alone. Ac-
companying these physical signs, the amphoric and metallic sounds
are quite prominent. The chief one is the clear click or tinkle, as of
water dropping in a well, heard with each inspiration and in the act
of coughing.
Life may continue for many years, yet the prognosis must rest
greatly on the fatality of the disorder causing the trouble. A cure is
not impossible.
Treatment. The therapeutics of phthisis, of pleuritis, of trau-
matism, or of empyema, may require to be consulted in different cases
of this disease. Thoracentesis should be performed only when the
symptoms are very urgent, and relief is absolutely necessary.
collapse which threatens the patient in the first onset of air entering
the pleural sac must be met with active measures and stimulants.
HÆMOTHORAX.
BY A. K. CRAWFORD, M.D.
This is the term given to a hæmorrhage into the pleural cavity.
The blood may come from the rupture of a vessel by injury, from a
diffuse pulmonary hæmorrhage breaking through into the pleura,
from an aneurism, or from a tuberculous or carcinomatous state of the
lungs or pleura; occasionally, the effusion in pleurisy is hæmorrhagic.
It is accompanied with dyspnoea, the result of pressure on the lung,
and the patient shows the usual symptoms of hæmorrhage, as pallor,
thirst, pinched features, ringing in the ears, and faintness. The physi-
cal signs are those of pleuritic effusion, and pleurisy occurs second-
arily in this affection as it does in pneumothorax.
328
A SYSTEM OF MEDICINE.
Treatment.—If traumatism has occasioned the bleeding, the
endeavor should be made to secure the injured vessel. If due to in-
ternal causes, the most that can be done in a general way is to keep
the patient perfectly quiet. Nor can much more than this be accom-
plished with our remedies. Wurmb believes that, if Arsenic will pro-
duce no beneficial change in the hæmorrhagic effusion of pleurisy,
nothing else will. The good effects of China for great loss of blood
are so well known that it requires no special commendation here.
The remedies used for external injuries under other circumstances,
such as Arnica, Calendula, and Hamamelis, may be of service when the
traumatic state occasions the hæmothorax.
TUBERCULOSIS OF THE PLEURA.
BY A. K. CRAWFORD, M.D.
Two kinds of tuberculosis of the pleura are distinguished: one
occurs as an accessory lesion of pulmonary phthisis, marked by more
or less inflammatory action; the other is a direct manifestation of
tubercular deposit on the pleura, independent of a similar condition
of the lung. The deposit is usually in the form of miliary granula-
tions scattered over the surface of the membrane. Or, if it is secondary,
the portion infiltrated will correspond with the locality of the lung
lesion and on the costal surface opposite. When the tubercles con-
gregate, the plaques generally occupy the upper and posterior aspect
of the pleura. The tubercles tend to gray degeneration or to the de-
velopment of a caseous state, but they nearly always preserve a con-
sistent form.
Acute tuberculosis of the pleura, as well as the same disease of the
peritoneum, or possibly of the meninges, is one of the common mani-
festations of acute phthisis. But chronic tuberculization of the pleura,
or pleural phthisis of some authors, is more often an idiopathic malady.
Reference is made to it in Laennec's writings, but most pathologists
neglect the subject. Latterly it has been perfectly described by Bar-
thez and Rilliet. They found it more common in children from three
to ten years of age than in adults. They describe the tubercles as de-
veloping either beneath the pleura, or on its free surface. In the
chronic form of tuberculosis they are nearly always intra-serous, in a
state of yellow granulation, and ordinarily accompanied by inflam-
matory pseudo-membranous deposits. The serous membrane below
the extra granulations is usually less inflamed than the portion sur-
rounding them for the space of about one-eighth of an inch.
The commencement of pleural phthisis is generally very insidious
and obscure. The signs accompanying this lesion are not well marked.
By inspection, the diseased side may be noticed to be slightly de-
pressed, preceded by some enlargement. The percussion resonance
DISEASES OF THE RESPIRATORY ORGANS.
329
is diminished without evidencing absolute dulness. The respiratory
murmur is feeble, while bronchial breathing is more distinct than in
health. Vocal resonance is augmented without attaining to egophony.
These signs are more pronounced at the back of the chest, and are not
modified by change of position. There is slight pain complained of,
slight dyspnoea, and a cough without expectoration. The patient
loses flesh, and is troubled with a remittent fever less marked than in
phthisis.
The development of the disease is slow and progressive, unless it is
complicated with other maladies. It is hastened very materially if
phthisis coexists. Patients with tuberculosis of the pleura finally
succumb to hectic fever and marasmus.
The diagnosis is certainly attended with many difficulties. The
physical signs afford no absolute distinction between the chronic in-
flammatory, suppurative, and tubercular diseases of the pleura. But
if to the general phenomena emaciation, hectic fever, and abundant
night-sweats are added, these symptoms prove really diagnostic of
tuberculosis, as compared with the pale and puffy face, the irregular
chills, and the persistent anorexia of purulent pleurisy. In numerous
cases thoracentesis will be the only means of clearing up all doubts
and establishing the knowledge of the presence or absence of a liquid
effusion.
CARCINOMA OF THE PLEURA.
Cancer of the pleura is usually a secondary affection, resulting from
cancer of the lung or of the breast. The calibre of the affected lymph
vessels of the pleura is greatly increased by the abundant deposit of
spherical endothelial cells, forming a whitish mass, more or less solid;
the lymph vessels are easily distinguished upon the pleural surface.
Of the forms most frequently found, the scirrhous and medullary
deserve mention; the granulations of the former are small and hard,
of the latter they attain considerable size, are softer, and, frequently,
depressed at the centre.
Cruveilhier's "Plaques sqirrheuses" are cancerous formations on the
pleural surface, small lenticular bodies which vary in size from thick-
enings which can scarcely be seen to distinct papular elevations, the
latter tending to the formation of pedunculated growths of the size of
grapes, or even larger; these may occur singly or in clusters, suspended
from the surface of the pleura. At a certain period of their growth
they resemble drops of tallow or wax, and are described as
drops."
66
wax-
Cancer of the pleura may give rise to neuralgia by pressure upon
the intercostal nerves.
This affection is of limited clinical importance, and the duty of the
physician, so far as treatment of the condition is concerned, is out-
lined in the chapter on "pulmonary cancer."
DISEASES OF THE ORGANS OF CIRCULATION.
A. THE HEART.
INTRODUCTORY.
BY PEMBERTON DUDLEY, M.D.
IN studying and in treating the diseases of the heart or the derange-
ments of its function, it is essential that the position and local rela-
tions of the organ, its general and minute anatomy, and its mechani-
cal and vital functions, should be clearly understood and constantly
remembered. Equally important is it to know, so far as may be, the
relationships which the heart sustains through its nerve connections,
and its physiological position in, and relation to, the whole series of
nutritive processes. All of the vegetative functions are dependent-
one upon another-for the maintenance of their regularity and effici-
ency, and serious disorder of any one produces, sooner or later, some
disturbance in one or more of the others. Between the heart and
the other organs this mutual relationship is peculiarly close, because
of the mechanical character of the cardiac function, and because of
the imperative necessity for that regular and efficient blood-supply
without which no organ can perfectly accomplish its vital task. Hence
it is that those disorders which follow in the train of serious and con-
tinuous heart diseases are nearly always found to depend upon ab-
normal conditions of the circulation affecting organs more or less re-
moved from the heart, and death, when it results from disease of this
central organ, is almost invariably due to mechanical changes in the
circulation of blood in distant parts. As affecting the opposite side
of this relationship, it is known that disorders of certain of the other
functions involve the heart in functional disorder or structural change,
sometimes speedily, sometimes gradually. Some of these cardiac dis-
orders are excited by reflex actions of the nerves involved, as when
digestive, respiratory or uterine derangements induce palpitation or
other irregularity of cardiac action. Some are of mechanical origin, as
when excessive carbonization of the blood impedes the flow through
the capillaries, or other obstructive agencies prevent its free egress
from the ventricles, and the excessive effort thus required of the organ
superinduces dilatation or hypertrophy. And some are essentially
nutritive, as when disease of the kidneys impairs the nutritive quality,
or disease of the coronary vessels diminishes the quantity, of blood
DISEASES OF THE ORGANS OF CIRCULATION.
331
supplied to the heart-muscle, and functional debility or structural de-
generation ensues as a direct consequence of the defective nutrition.
It thus becomes apparent that disease of the heart may exist either
as a cause or as a result of maladies affecting other parts of the
organism; and, considering the liability of these various parts to
the disorders which are likely to react upon the cardiac function,
there can be no wonder at the prevalence of heart disease in numerous
forms.
The Structure of the Heart.-The heart is a powerful, muscular
organ, somewhat irregularly cone-shaped, situated in the anterior
portion of the thoracic cavity, the base of the cone occupying the me-
dian space, but looking upward, backward, and to the right, and the
apex pointing downward, forward, and to the left. It is usually de-
scribed as being "suspended "-it really is attached to the neighboring
organs and tissues by means of the great vessels which spring from its
base, some of which pass laterally to the lung on each side, while the
aorta arches upward and backward to a quite firm attachment at the
upper and posterior portion of the thoracic walls. The body of the
heart is quite freely movable. It is inclosed in the pericardium, a
fibrous sac, the lining of which is reflected over the body of the heart,
and forms its closely adherent, external tunic. This reflected and
lining pericardial membrane is serous in character, and secretes a
watery, alkaline, albuminoid fluid, which lubricates the opposing
surfaces and reduces the friction of the heart's movements to a mini-
mum. The sac usually is found, post-mortem, to contain from one to
two drachms of this serous fluid, though a somewhat larger quantity
is not regarded, necessarily, as an indication of disease. Externally,
the pericardium is attached below to the diaphragm, anteriorly by the
sterno-pericardial bands to the sternum, superiorly to the cervical
vertebræ and hyoid bone, laterally to the mediastinum, and posteriorly
by loose connective tissue to the bronchial and œsophageal tubes, etc.
Paul directs special attention to the firmness and strength of the liga-
ments or bands which connect the pericardial sac with the third
cervical vertebra, the hyoid bone, and the sternum above, and to the
broad and firmly adherent base which rests upon the tendinous centre
of the diaphragm below, and which together serve to render the sac
"next to the pelvis, the least movable region in the human body."*
These points of fixation seem to determine a pyramidal shape to the
pericardium, the base resting on the diaphragm, and the apex extend-
ing to the upper limit of the thoracic cavity,-not corresponding,
therefore, to the position of the cardiac pyramid as already described.
Correctly speaking, the heart is an irregular triangular pyramid, not,
however, resting upon, nor suspended from, its geometrical base, but
* Diagnosis and Treatment of Diseases of the Heart. By Constantine Paul. Wm.
Wood & Co., New York, 1884.
332
A SYSTEM OF MEDICINE.
lying upon one of its triangular sides. This side, which thus forms
the mechanical base of the organ, rests upon the tendinous portion of
the diaphragm, which, in this situation, is not quite horizontal, but is
inclined slightly downward, forward, and to the left. The triangular
portion of the cardiac surface which thus rests upon the diaphragm,
is somewhat flattened, and is made up almost equally of the right
and left ventricles, while the right auricle also enters into its formation.
The anterior surface of the heart is nearly vertical; it is also approx-
imately triangular, and is somewhat flattened, so as to correspond to
the opposing posterior surface of the sternum and costal cartilages.
The base line of this triangle is nearly straight, and extends from the
apex of the heart to the junction of the ascending vena cava. The
apex, in the vast majority of adults, is found in the fifth intercostal
space, from 3 to 4 inches to the left of the median line. Many writers
mention this point as being a short distance within a perpendicular
drawn through the left nipple; but actual measurements show that
even in men the distance of the nipple from the median line may be
as small as 3½, or as great as 5 inches. A more reliable measurement
for the diagnostician, therefore, is the one first given. In childhood
the apex is sometimes found behind the fifth rib or even in the fourth
intercostal space, while in old age it may be as low as the sixth space.
The position of the apex is liable to great variation in disease, particu-
larly in cases of hypertrophy, dilatation, etc., and constitutes, there-
fore, a most important element of diagnosis. The point of insertion.
of the ascending cava is the right inferior angle of the anterior cardiac
triangle. This point is best located in the living subject by first deter-
mining, by careful percussion, the perpendicular outline of the heart,
which runs nearly parallel to the right edge of the sternum and about.
one or one and a half inches to the right of the median line; then,
defining in a similar manner the line between the resonance of the
right lung and the dulness of the liver, and propagating these two
lines to their intersection, we can locate the exact position of the right.
inferior angle. It will thus be found located a half inch or an inch
to the right of the sternal junction of the right fifth rib. It will also
be seen that the base line is not exactly horizontal, but inclines down-
ward and to the left. In left ventricular hypertrophy the apex is
usually depressed, and the obliquity of the base line increased. In
right auricular hypertrophy, the obliquity is diminished, not so much
by depression of the right inferior angle as by an increased convexity
of the lower border of the auricle. Other changes in the form, volume,
or weight of the heart also produce changes in the relative position of
these lines and angles. These will be duly considered in their appro-
priate place.
The superior angle of the anterior cardiac triangle is located in the
second intercostal space, about an inch to the right of the median line.
DISEASES OF THE ORGANS OF CIRCULATION.
333
The two sides of the triangle which form this superior angle are both
convex outwardly. The right inferior angle is slightly obtuse.
It is necessary, in the clinical examination of the heart, to remember
that the organ is partly covered, in front, by the overlapping borders
of the lungs. As a result of this circumstance, the character of the
sounds elicited by superficial percussion over the covered portions of
the heart will be greatly modified. A portion of the heart, however,
comes into direct relation with the thoracic wall, only the two layers
of pericardium intervening. This uncovered portion occupies a
space known as the "area of superficial cardiac dulness." It is tri-
angular in outline, and its boundary, beginning in the median line
opposite the fourth costal cartilage, runs downward and outward
nearly, or quite, to the cardiac apex (it sometimes happens that the
apex is itself covered by the lung), thence along the base of the ante-
rior cardiac triangle to the median line, and thence upward to the
point of departure. This area, variable as it is in size and outline,
furnishes better opportunity for studying certain of the heart's symp-
toms and conditions than do other portions of its anterior aspect. The
space may be encroached upon by emphysema, or extended by car-
diac hypertrophy or dilatation, but especially by pericardial exuda-
tions, dropsy, etc.
Luschka has made the location of the various portions of the heart
the subject of special experimental research. He made a median sec-
tion of a frozen body, and found on the right side of the section all of
the right auricle, about half of the left auricle, and a small portion of
the right ventricle; on the left side he found half of the left auricle,
nearly all of the right ventricle, and the entire left ventricle.
Mensuration of the heart exhibits remarkable differences among
different observers. This is not surprising when it is remembered
that the volume of the organ varies under the different modes of death,
and perhaps to some extent under the post-mortem conditions. Profes-
sor A. R. Thomas, in his well-known treatise on Post-mortem Examinations,
gives the length of the normal heart as about five inches, its breadth
(bilateral diameter) three and a half inches, and its thickness (antero-
posterior diameter) two and a half inches. The weight is set down
by the same authority as averaging nine and a half ounces in the male,
and eight and a quarter in the female, though "in the robust, muscular
male, it may be found to weigh as much as twelve ounces, and yet be
normal in all its parts." Bizot, as cited by Schrotter (vide Ziemssen,
vol. vi., p. 202), estimates the length at 3, breadth 4, and thick-
ness 1% (?) inches in males, the average in females being somewhat
less. Flint gives the average weight of the heart in the male as 10 to
12 ounces, and in the female 8 to 10 ounces.
Very much of the difference in measurements must, as already in-
timated, be ascribed to variation in the phase-systole or diastole—at
334
A SYSTEM OF MEDICINE.
which death occurred, and, doubtless, much also to the arbitrary and
ill-defined method of including or excluding the exceedingly variable
dimensions of the auricles.
In the formation of the heart, the right ventricle has a somewhat
different shape from the left, the latter being more nearly conoidal
than the former. A transverse section through the left ventricle is
nearly circular in its general outline, while that through the right is
somewhat crescentic in shape. The right ventricle approaches nearly,
but not quite, to the point of the heart, so that the apex is composed
of the tissues of the left ventricle exclusively. This is doubtless the
reason why left valvular murmurs are heard so much more distinctly
at the apex than are those produced on the other side of the heart.
The walls of the left ventricle are considerably thicker than those of
its fellow, in whatever portion they may be measured. Near the base
of the ventricle the thickness exceeds half an inch on the average,
while in the corresponding portion of the right ventricle it is scarcely
more than one-fifth of an inch. Much, however, depends upon the
general muscular development of the subject, and much more upon
the phase in which the measurements are made. The auricles have
much thinner walls, that of the left being about one-eighth, and that
of the right about one-twelfth of an inch.
The size of the cavities is exceedingly important to the pathologist,
particularly in estimating the amount of a cardiac dilatation or hyper-
trophy, and yet, unfortunately, our information on this point is ex-
ceedingly indefinite, and any figures given must be received with
caution. Perhaps the most reliable data as to the extreme capacity of
the ventricles are those obtained by Hiffelsheim and Robin, and
quoted by Flint. These observers found the capacity of the left ven-
tricle, when distended to the utmost, to be from 4.8 to 7 ounces, and
that of the right about one-tenth to one-eighth greater. These figures,
however, are of little real value to us, since the heart, either in health
or in disease, is never distended to its utmost, but is expanded only
moderately by its contained blood. The measurements given by Bizot,
and corroborated by Ducastel, when reduced to fluid-ounces, are for
males, left ventricle, about 2; right, about 28; females, left, 2; right,
22. Stated in general terms, it is generally considered that each ven-
tricle discharges about two ounces of blood at each systole. There is
little doubt that the capacity of the right ventricle is a little greater
than that of the left (possibly due only to its greater distensibility), but
the actual discharge must, on the average, be practically equal for the
two chambers. The capacity of each auricle is a little less than that
of its corresponding ventricle, and this difference is said to increase
with age.
It is quite well established that the heart does not acquire its full
development until the age of about thirty years, that it maintains its
DISEASES OF THE ORGANS OF CIRCULATION.
335
size quite uniformly from that time until the age of sixty, and then
increases again in volume slightly until death. At the period included
between thirty and sixty years, the average weight of the entire organ,
as shown by Ducastel's tables, is, in males, 308 grammes; and in
females, 276 grammes. The average weight of the left ventricle is, in
males, 173 grammes; and in females, 150 grammes. That of the right
ventricle, in males, 72 grammes; and in females, 62 grammes. These
tables, however, show a remarkably wide difference between the mini-
mum and maximum weights, extending all the way from 205 to 580
for the entire heart, from 120 to 375 for the left ventricle, and from 45
to 130 for the right ventricle. As respects the weights and dimensions
above given, we quote the words of Constantine Paul, as showing the
value to be attached to them in post-mortem examinations:
"The average weight of the heart in the adult being 300 grammes,*
I can be positive that hypertrophy existed if the weight exceeds this
figure to any considerable extent. The volume furnishes perhaps a
less certain means of judgment, because the heart may be arrested
either in systole or diastole. Cruveilhier states that the heart is
arrested in systole, and has a much smaller volume in all those who
die a violent death or rapidly bleed to death. He adds that if the
fingers be introduced into the hearts of such individuals, they may be
dilated with surprising facility. In fact, the manner of death and
the cadaveric rigidity notably affect the results.
"The thickness of the walls may also furnish sources of error. The
heart of a child is found much more retracted than that of an adult;
this is also true of those who have suffered a violent death or died of
hæmorrhage. If this condition, accordingly, is not accompanied by
an increase in the total weight, it does not signify hypertrophy."t
The valves, by which the course of the blood is determined, are
dense, resisting curtains covered with folds of the endocardial mem-
brane. The auriculo-ventricular valves are reinforced by means of
the chorda tendineæ springing from the papillæ, or directly from the
ventricular walls, and attached to the free borders of the valve cur-
tains. The cords prevent the sail-like curtains from being forced
entirely through the openings, and thus they aid in securing the per-
fect closure of the auriculo-ventricular inlets. The pulmonic and
aortic (semilunar, or sigmoid) valves are quite similar in structure,
and are provided with a small, firm body, the corpuscle of Arantius,
at the middle of the free border of each curtain, to secure a more
effective closure of the outlets and prevent regurgitation. The valves.
are peculiarly liable to a class of diseases which affect their form,
flexibility, elasticity, or mobility, and thus either cause obstructions
to the free passage of blood, or admit of regurgitation.
* I.
e., 10.58 avoirdupois ounces.-D.
† Diseases of the Heart. New York. William Wood & Co. 1884.
336
A SYSTEM OF MEDICINE.
The muscular structure of the heart's walls is sometimes described
as occupying a position intermediate between the voluntary and the
involuntary systems of muscular apparatus, i. e., it shows the deep-
red, highly-nourished, striated appearance of the skeletal muscles,
and acts with their tremendous vigor and energy, while yet its move-
ments are entirely beyond the control of the will-power, and exhibit
a regular and unflagging rhythmical action to which the voluntary
muscles are strangers, and which they could not long sustain. This
leads us to a brief consideration of certain matters respecting the
heart's function, in connection with which we shall allude, more par-
ticularly, to its supply of nutritive blood, and to its peculiar relations
to the cerebro-spinal and lymphatic nervous systems.
The Functions of the Heart.-The systemic return-blood, flow-
ing from the great veins, is received into the right auricle, and passes
freely through the auriculo-ventricular opening into the right ventricle.
until both chambers may be said to be filled, yet not distended. At
this moment the auricle contracts (auricular systole) with considerable
force, impels an additional portion of the blood into the ventricle, and
immediately relaxes again. Instantly the moderately distended ven-
tricle contracts (ventricular systole) upon its contained blood, the
auriculo-ventricular (tricuspid) valve closes with a snap, and the whole
mass of blood is directed into the pulmonary artery through the pul-
monic or sigmoid valves. With scarcely an interval of quiet, the
ventricle relaxes (diastole) to receive its next charge, the elastic walls.
of the pulmonary artery react upon their contents, the sigmoid valve
closes suddenly, and the volume of blood is driven forward into the
lungs. The auricle, as already stated, relaxes (auricular diastole) at
the beginning of the ventricular systole, and again is ready to receive.
blood from the great veins. The whole series of changes, together
with a relatively long period of repose which intervenes before the
next auricular systole, occupies, in the adult, a little less than one
second. At the same time a precisely similar series of movements is
taking place in the left side of the organ. The pulmonic return-blood
flows from the pulmonary veins, down into the left auricle, through
the left auriculo-ventricular opening (mitral valve) into the left ven-
tricle, until both chambers are filled; the auricle contracts, drives a
portion of its blood into the ventricle, and immediately relaxes. At
this moment the distended ventricle contracts, the mitral valve in-
stantly closes to prevent regurgitation, the aortic valve opens, and the
blood rushes through into the great systemic artery; the ventricle
relaxes, the mitral reopens to admit the succeeding influx; the dis-
tended but elastic aorta reacts upon its blood, the aortic valve promptly
closes to prevent reflux, and the left ventricular blood is driven onward
into the smaller systemic arteries by the combined force of the ven-
tricular impulse and the more uniform pressure of the elastic aortic
DISEASES OF THE ORGANS OF CIRCULATION.
337
walls. The two auricles contract and relax simultaneously, as do also
the two ventricles. Indeed, so exactly synchronous are the corre-
sponding movements of the two sides, that the sounds of the two sets
of valves reach the ear of the auscultator as though produced by one.
This, as we have briefly described it, constitutes a "revolution" of the
heart, and includes a single filling and emptying of all its cavities, a
single opening and closing of all its valves, a single contraction, relaxa-
tion, and period of repose of all its muscular tissue.
The auricular systole probably forces but a comparatively small
amount of blood into the ventricle. The pressure exerted by it may
impel the blood in large quantity backward into the communicating
veins, since there are no valves in these localities to intercept its retro-
grade flow. This regurgitation, however, is not sufficient, in the right
side of the heart, to create a perceptible impulse in the neighboring
large veins, and whenever a jugular, brachial or hepatic venous pulse
is observed, it is regarded as abnormal, and due probably to tricuspid
regurgitant lesion.
The time occupied by the various parts of a cardiac "revolution "
has been defined by Marey, Chauveau, and others, with mathematical
precision. From repeated observations made by the first-named in-
vestigator it appears that-
1. The auricular systole occupies two-tenths of a revolution, and is
followed immediately by the auricular diastole.
2. The ventricular systole begins immediately upon the completion
of the auricular systole, and occupies four-tenths of the revolution.
3. The ventricular diastole, including the period of repose which
preceded the next succeeding auricular contraction, occupies four-
tenths of the revolution.
It is well known to physiologists, however, that although Marey, with
his cardiograph, has been able to draw a sharp line between the con-
traction of the auricle and that of the ventricle, yet practically the
systole seems to consist of a single gradual movement which, begin-
ning in the auricle, is rapidly propagated, like a peristaltic wave of
contraction, down to the apex. The cardiograph simply measures the
exact period during which systolic pressure is maintained upon the
contents of each chamber.
As regards the true relation which the systole and diastole hold to
the movements of the valves, the writer has always been careful to
impress upon the student the fact that the auricular diastole has no
causative relation to the closure of the auriculo-ventricular valves, and
the ventricular diastole no influence whatever in causing the closure
of the sigmoid valves. The fact that these phenomena occur synchro-
nously has, to my knowledge, misled some into the erroneous belief
that the one is dependent upon the other; whereas it is known that if
the heart's action should be suddenly arrested in systole, its last con-
VOL. I.-22
338
A SYSTEM OF MEDICINE.
traction would still be followed by a final "click" of the sigmoid
valves. The error, trifling in itself, perhaps, may lead to a misconcep-
tion of certain causes which may modify the intensity of the valve
sounds, as, for instance, a weakened ventricle in the one case, or a loss
of arterial tonicity in the other.
The muscular fibres composing the cardiac walls have a twofold
arrangement. In the first place, each side of the heart has its own
muscular fibres, which exert no action upon the opposite side; and,
in the second place, there is a layer of fibres which pass around both
ventricles. The contraction of these latter must, of course, determine
the synchronous action of the two ventricles, even if there were no
nervous influence operating to produce it.
The mechanical force required to drive the blood through the distant
systemic capillaries must be much greater than that necessary to
carry on the smaller pulmonic circulation, and the greater thickness
of the left ventricular walls is simply a natural adaptation to a greater
requirement. This fact is mentioned here to show the perfectly nor-
mal and physiological nature of that process which leads to hyper-
trophy, or thickening, of the wall when any increased muscular force.
is continuously necessary to overcome abnormal resistances to the free
circulation of the blood, e. g., valvular stenosis, constriction or com-
pression of the aorta, etc. It also serves to indicate what must be the
natural results-anæmia, defective nutrition, etc.-in even distant
organs when the heart's mechanical action is weakened by atrophy,
fatty degeneration, diminished normal irritability, etc.
To the pathologist, an understanding of the physical changes which
the heart undergoes at each revolution is essential, as it furnishes the
key to an appreciation of those phenomena which, to the physician,
constitute the chief elements in both physical and subjective diagnosis.
These physical manifestations are: 1, hardening; 2, twisting of its
apex; 3, increase of its antero-posterior, and decrease of its bilateral
diameters; 4, shortening of the ventricles; 5, thrusting of the apex
downward and forward, i. e., in the direction of its axis, due, doubtless,
to the bulging outwards of the thin walls of the heart's base, and to
the distension of the great arteries by the ventricular blood; 6, tilting
of the apex forward and to the right, due largely to the causes just
mentioned, and to the increase of the antero-posterior diameter of the
heart at, and near, the base of the ventricles. All these occur at the
moment of the ventricular systole, and the twisting, the thrusting
downward and forward, and the tilting forward and to the right, to-
gether, constitute the "impulse" or "beat" of the heart, by which its
apical portion is pressed firmly and suddenly against the tissues
forming the anterior chest-wall at each ventricular systole.
At each revolution of the heart there are also produced two distinct
sounds, described by physiologists as a "long" and a "short"—a
DISEASES OF THE ORGANS OF CIRCULATION.
339
(( first" and a "second" sound. The first, or long, sound occurs syn-
chronously with the ventricular systole, and its length corresponds
very closely to the duration of the systolic movement, i. e., about four-
tenths of the cardiac revolution. The second, or short, sound takes
place immediately after the close of the ventricular systole, and its
length is not measurable by the unaided ear, being produced by the
short, sharp "clap" of the pulmonic and aortic valves, and in tissues
not capable of prolonged sonorous vibration. Perhaps it is safe to say
that the perfectly normal second sound does not occupy much more
than one-tenth of the heart's revolution, although Flint ventures to esti-
mate it at three-tenths. The timbre, or quality, of the sound is of vastly
more importance to the practitioner than an accurate measurement
of its duration, since changes in its quality under the influence of dis-
ease are always found to coexist with variations in its length, and are
far more easily understood and appreciated. Between the first and
second sounds there is a perceptible, though not a measurable, in-
terval, and between the second and next succeeding first-sound, a
much longer period of silence. The writer estimates the duration of
the respective sounds and intervals as follows:
Duration of first sound,
Interval of silence,
4 tenths of a revolution.
1 tenth of a revolution.
Duration of second sound, 1 tenth of a revolution.
4 tenths of a revolution.
Interval of repose,
The cause of the second sound having been already mentioned, it
remains to be said that the first sound has a manifold cause, compris-
ing (1) the closure of the auricular valves at the very beginning of the
sound; (2) the muscular contraction of the heart walls; (3) the move-
ment of the heart in its impulse or "beat" against the thoracic wall;
and (4) the rush of blood through the great arterial outlets. The last-
named of these causes is not mentioned by some physiologists. The
pathologist, however, becomes aware of its value by the marked
changes in the sound produced by even the slightest narrowing of
these outlets, or by the thickening or roughening of the valves over
which the escaping blood is flowing.
The general causes of changes in the heart sounds, being purely
mechanical in their operation, are not very difficult to understand, al-
though, like other disease-symptoms, they are not unfrequently mis-
leading. It is essential that we remember all the movements and
phenomena occurring in the heart at the moment when the abnorm-
ality is observed, and, moreover, we must note the exact locality at
which the unusual sound is heard in its greatest intensity. Then,
having carefully studied all the coexisting circumstances of the case,
an accurate diagnosis of the morbid condition can usually be arrived at.
Both the cardiac sounds can usually be heard over the entire præcor-
340
A SYSTEM OF MEDICINE.
dial region, and, in certain directions, to a considerable distance be-
yond it. But there are localities at which certain elements of the
sounds reach the ear with greater intensity than elsewhere, and at
these points the qualities of these elements and their morbid altera-
tions can be best studied. According to Guttman, and others, the
sounds originating in the mitral orifice are best heard at, or a little
above, the apex; those produced at the tricuspid opening, at the lower
end of the sternum; those of the aortic opening, in the second inter-
costal space at the right edge of the sternum, and those of the pul-
monary orifice, at a corresponding point at the left edge of the sternum.
But there are numerous causes which, in disease, modify this general
statement, and in practice these points of maximum intensity should
be carefully sought out in each and every case examined. It should
be mentioned that, in any case, the sounds which reach the ear when
placed over the body of the heart, are rendered less distinct, during
inspiration, by the encroaching borders of the air-distended lungs;
also by the supine posture, which allows the heart to gravitate away
from the ear and diminishes the force of the impulse, and also by any
increase, either muscular, osseous or adipose, in the thickness of the
intervening thoracic wall. Furthermore, their intensity is also modi-
fied by various morbid changes in and around the organ, all of which
must be considered in their appropriate places.
Diseases of Nutrition of the Heart.-As the heart is peculiarly
subject to diseases affecting its nutrition, a brief consideration of the
physiology of that function, as it applies to the organ we are studying,
becomes imperative. The most important of these diseases are hyper-
trophy, atrophy, degeneration, infiltration, etc.
The causes of the regular rhythmical movement of the heart will
presently be considered. We are now concerned with the fact of its
necessity. Other muscles, after periods of activity, take their long.
intervals of perfect repose. But a single and relatively brief period of
rest of the heart is fatal to the organism. Its alternate contraction and
relaxation is, and must be, incessant and unflagging. The contraction.
of a skeletal muscle forces blood out of its meshes, and thus impairs,
for the time, the activity of nutrition in its own tissues. Is the same
statement true of the cardiac muscle? This particular muscle receives
its arterial blood through the coronary arteries from a point just above
the ventricular outlet, and where, at the period of the ventricular sys-
tole, the pressure is enormous. It is plain that as this pressure repre-
sents the equal of the compressive force in the cardiac tissues, there
can be no regurgitation of coronary blood. Lannelongue, however,
has shown that during the ventricular systole a large proportion of
the blood is driven by compression out of the coronary veins. But it
may well be doubted if this compression seriously affects the quantity
in the cardiac capillaries, else it would seem impossible that the
DISEASES OF THE ORGANS OF CIRCULATION.
341
requisite irritability of its tissues could be maintained. The heart is
fully as easily affected by a deficient blood-supply as is any other
muscle. Obstruction of the coronary arterial trunks by a tumor, or a
ligature, or a greatly diminished blood-pressure in the aorta, cutting
off the coronary supply, may speedily result in heart-failure and sudden
death. It is in this latter mode, undoubtedly, that numerous fatalities.
occur in rapidly exhausting disease, such as Asiatic cholera, etc., or in
severe shock; the tension of the arterial coats becoming rapidly, or even
suddenly, weakened, the blood-pressure in the aorta suddenly falling
to a minimum, the heart is deprived of its nutritive supply, and car-
diac failure follows as the certain result.
The Nervous Relationship of the Heart.-Concerning the
nervous connections and relations of the heart, though, as yet, much
is obscure, and many of the views held may prove erroneous, we pos-
sess sufficient positive knowledge to indicate that this organ has a
nervous relationship strikingly unlike that of any other part of the
organism. It has been amply demonstrated that the heart enjoys a
remarkable independence of both the cerebro-spinal and the sympa-
thetic nervous systems, and is capable of maintaining a somewhat
regular and persistent action after being entirely cut off from anatomi-
cal connection with both. The simple and oft-repeated experiments
by which this fact is demonstrated are laid down in all physiological
text-books, and need not be described here. The constant and long-
continued rhythmical action of the heart, removed from the body of a
frog or of an alligator, was long supposed to be due to an irritability
precisely like that which exists in all muscles. Subsequently, it was
discovered that there are in the substance of the heart certain aggrega-
tions of ganglionic cells, possessing the properties of other nerve centres,
and it has been shown that these cells exert a stimulating and control-
ling influence upon the heart's contractions. But even these do not
account for the regular rhythmical cardiac movements, for it is shown.
that the apical portion of the heart contains no ganglion cells what-
ever, and yet a portion cut from near the apex of a frog's heart con-
tinues to contract and relax with more or less regularity for a con-
siderable period. It is now generally held that the causes of the
heart's continued and regular actions are threefold: First, that there is
a cerebro-spinal, and also a sympathetic, communication (which has
been amply demonstrated anatomically as well as physiologically)
now quite well understood, and which will be further considered
presently; secondly, that the cardiac ganglion cells, just mentioned,
possess, somewhat like the cerebro-spinal and sympathetic cardiac
nerves, a stimulating action upon the heart's function; and thirdly,
that the muscular tissue of the heart possesses an independent power of
rhythmical contraction-an irritability of a character peculiar to itself,
and quite unlike that of ordinary muscles. As a result of this irrita-
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A SYSTEM OF MEDICINE.
bility, a portion of the frog's heart, destitute of ganglionic cells, will con-
tract rhythmically, if constantly stimulated; but if some of the gan-
glionic cells are attached to the separated portion, rhythmic action goes
on for a time without artificial stimulation. It is also evident that the
contraction of one portion of the fibres acts as a stimulus to the con-
tiguous fibres, and that in this way the peristaltic wave of contraction
is propagated from base to apex, but that in the absence of a special
stimulus a ganglionic excitation is requisite. This, with the known
fact that contraction begins in the auricles, would lead us to the infer-
ence that the ganglion cells are chiefly located about the base of the
heart, and this inference is confirmed by numerous investigators who
have found these cells most numerous in the walls of the auricles and
in the auriculo-ventricular groove, while, according to Bidder, there
appear to be none in the substance of the ventricles.*
In addition to this intracardiac nervous system, the action of the
extrinsic nerves must be briefly considered. These are partly of
cerebro-spinal and partly of sympathetic origin, the former consisting
of fibres reaching the heart through the great pneumogastric trunks.
These two kinds of nerves unite in the cardiac plexus, from which
numerous branches are given off to the heart, in whose substance they
exhibit peculiar terminations, forming plexuses whose meshes are.
large enough to receive a muscle-fibrilla, and from which minute.
fibres enter the muscle-cells. (Ranvier.)
As the result of almost numberless experiments upon the pneumo-
gastric nerves and their roots and branches, it is demonstrated that
these nerves possess a function not seen elsewhere in the human or-
ganism, at least not in the form and manner in which it is here mani-
fested, viz., the function of inhibition, the power to retard or arrest
muscular contraction. If these nerves be divided, the heart's action
is accelerated, while if they be galvanized, or otherwise stimulated, the
cardiac movements are retarded notably, and in case the stimulation
is sufficiently energetic, the heart's action is arrested in systole. It is
also determined that the fibres possessing this inhibitory function are.
derived from the internal anastomotic branch of the spinal accessory
nerve, that these fibres are efferent or centrifugal in function, and that
the inhibitory function of these fibres, therefore, is direct, and not
reflex, though it seems to be established that the function can be
reflexly excited. This inhibition, or retarding function, can be tem-
porarily augmented in various ways, as by emotions of fear or terror,
by increased intracranial blood-pressure, by diminished supply of
arterial blood to the pneumogastric centres (Yeo), as well as by certain
drugs, such as Digitalis, Muscarine, etc.
On the other hand, it is found that stimulation of the sympathetic
* Yeo's Physiology. Presley Blakiston, Phila., 1884.
DISEASES OF THE ORGANS OF CIRCULATION.
343
in the neck, or at any point in the course of the fibres toward the
heart, causes a remarkable acceleration of the cardiac contractions.
The duration of the systole is not increased, but as the revolution is
very greatly diminished, there is little time for diastolic repose, the
ventricles are but partially filled, so that the aggregate quantity of
blood discharged into the arteries is not much, if at all, increased, and
the arterial pressure is not raised much above the normal.
Of the centripetal or sensory cardiac nerves there are two to be de-
scribed. First, the nerve of Ludwig and Cyon. It begins in the
heart, and passes along the pneumogastric trunk, and into the medulla
oblongata. Its irritation in the rabbit elicits cries of pain. Secondly,
certain fibres discovered by Franck in 1880. These latter start from
the endocardium also, and reach the medulla oblongata. Both these
nerves appear to be sensitive to an excess of intraventricular pressure,
and both are evidently designed to prevent or relieve such excess.
One of them acts upon the cardio-inhibitory centre, diminishing the
rapidity of the heart's action, and the other excites the vaso-inhibitory
function, dilating the arteries, and thus diminishing the arterial pres-
sure. Thus it seems that, so far as the nervous system can supply
them, the heart's safeguards are perfect and complete.
This consideration of the function of the heart, with a direct view
to the study of its pathology, would not be complete without a brief
reference to some of the numerous modes in which the action of this
all-important organ may be brought to a stand-still.
First of all, it is observed that, the heart's action being purely mus-
cular, any form of degeneration which changes the character of the
tissue must correspondingly weaken its walls, and this may go on un-
til the debilitated and overworked organ abandons its functions from
sheer exhaustion. In this manner is death to be explained in cases
of fatty degeneration, with sudden arrest of the cardiac function.
Second, the heart's action may be interfered with by immense accumu-
lations of fat in or upon its walls, loading it down and constantly ob-
structing its free movements, or by extensive adhesions of its pericardial
membrane. Third, pressure upon its external surface, c. g., a pericar-
dial dropsy or hæmorrhage, or an extensive pleuritic effusion, may so
antagonize the diastole as to prevent the filling of its cavities from the
great veins, and its action ceases for want of sufficient space and suffi-
cient stimulus. Fourth, inability to completely empty its ventricles,
because of obstructive lesions at the aortic orifice, or in the course of
the aorta, or even in the systemic capillaries, may result in ventricu-
lar engorgement, enormous distension of the muscular walls, mechan-
ical strain, and rapid and complete exhaustion. Fifth, obstruction to
the influx of blood, as by the pressure of an aneurismal, or other, tumor
upon the great veins, may rob the heart of both its nutritive and its
stimulant supply, and sudden failure may follow. Sixth, anemia, the
344
A SYSTEM OF MEDICINE.
exhaustion of prolonged disease, or hæmorrhage, may so diminish the
aggregate of blood as to diminish the intravascular pressure, and cor-
respondingly diminish the natural stimulus to the heart's cavities.
Seventh, the same causes, diminishing the pressure within the aorta,
cut off the requisite and full supply to the coronary arteries, and the
starved muscular tissue of the heart soon exhausts its contractile irri-
tability. Eighth, rapid exhaustion of nerve power in exhausting dis-
eases, shock of injuries or surgical operations, may paralyze the
vaso-motor functions, diminish the blood-pressure, and thus deprive the
heart of both food for its tissues and stimulus for its cavities. Ninth,
incomplete aeration of the blood may gradually deprive the walls of
the ventricles of their nutrient supply, until they are no longer able to
accomplish their ceaseless task. Tenth, undue excitation of the inhib-
itory centres may cause sudden arrest of the heart in diastole. In
these, and in numerous other, ways the action of the heart may be
interfered with, and, of course, always with fatal effect.
B. DISEASES OF THE ENDOCARDIUM.
BY E. M. HALE, M.D.
ENDOCARDITIS-INFLAMMATION OF THE ENDOCARDIUM,
Synonyms.-(French) Endocardite; (German) Endocarditis.
Definition. With the diseases of the endocardium we begin the
study of the diseases of the heart itself. The endocardium is the
lining membrane of the cavities of the heart, and forms its valves; an
inflammation of this membrane is called endocarditis.
Varieties. Simple endocarditis may be divided into acute, sub-
acute, and chronic, but the distinction is of little practical value, and
chronic endocarditis bears such a close relation to affections of the
valves, that its study is best made under that head.
Ulcerative or diphtheritic endocarditis is another variety, and as the
distinction here is more sharply defined, the study should be conducted
under these two divisions.
SIMPLE ENDOCARDITIS.
Endocardial inflammation is generally localized on the valves and
chordæ tendineæ. After birth it is generally limited to the left side of
the heart, and in the rare cases in which the right side is involved, the
left is involved also. Before birth the reverse is true; in the vast ma-
jority of cases in which fœtal endocarditis has been observed, it has
been confined to the right side. (Flint.)
Etiology.-Primary or idiopathic endocarditis is rarely met with,
DISEASES OF THE ORGANS OF CIRCULATION.
345
the disease occurring rather in complication with others; it may be
secondary to pleuritis, pneumonia, and other febrile conditions, and
is, as a rule, associated with pericarditis; in fact, an inflammation of
the pericardium seldom fails to establish a sympathetic inflammation
of the endocardium, then called endo-pericarditis. The principal
disease with which endocarditis associates itself is acute rheumatism;
and as trouble with the heart is closely connected with troubles of the
kidneys, endocarditis often follows, or accompanies, the varieties of
Bright's disease.
It is said that in non-rheumatic endocarditis the aortic valves are
more likely to be the seat of inflammation than the mitral, the reverse
being true of rheumatic endocarditis.
When the inflammation develops in the course of acute rheumatism,
it is not from transference of affections of the joints to this membrane,
but rather the result of a bad condition of the blood [claimed by some
pathologists to be due to lactic acid, C,H,O,], and hence it is often
found in cases of pyæmia and septicemia. Chorea, in its analogy to
rheumatism, often carries endocarditis with it.
3
A modifying factor is the age of the affected person, endocarditis
being more rarely found in young persons than in the aged.
Traumatic causes may set up endocarditis, but such cases are few.
Pathology. As the disease is so seldom distinct, the ante-mortem
examination is best studied through the symptoms, while the ana-
tomical characteristics can be ascertained only by the appearance
after death.
Fothergill says: "The first stage is that of injection redness, where
the endocardium is injected with points of branch-like vascularity.
This is rarely seen, in consequence of the fatality of endocarditis lying
rather in its consequences than in its immediate results. This in-
flammatory condition must not be confounded with the mere stain-
ing of the endocardium after death." The serous membrane swells
and is thickened, especially the free edges of the valves." "On the
surface of the endocardium are found vascular growths, villi, often in
small aggregations, giving the appearance of warts. These must not
be mistaken for mere fibrinous adhesions to the surface of the valves
from deposit of the fibrin of the blood,-mere strings of fibrin, usually
found on a surface over which the blood-current rushes. This endo-
cardial inflammation is usually accompanied by inflammation of the
muscular coat beneath it. The muscular papillaries are usually
affected not only by the inflammation spreading over their surface,
but also by their structure becoming involved, which leads frequently
to irregular action, and to insufficient closure of the valve, especially
during the early attack."
The endocardium is swollen, velvety, and, as has been noticed, red
in the early stages, but as acute inflammation is apt gradually to
346
A SYSTEM OF MEDICINE.
merge into chronic, this redness subsides, and the appearance may be
opaque, not transparent, puckered and thickened by the growth of
connective tissue. Calcareous changes may be noticed in the de-
posits, fatty degeneration takes place, and the formation of aneurisms
is seen.
Symptomatology. The symptoms of simple endocarditis are
less distinctive even than those of pericarditis, and are inseparable.
from the symptoms of the disease with which it is associated, and the
diagnosis of it should depend largely upon physical signs. Occur-
ring generally in connection with acute rheumatism, its indications
are merged into those of the latter affection. In a large number of
cases there are no symptoms which attract attention particularly to
the heart as the seat of the disease; examination, however, with a
view to determine the presence or absence of phenomena which point
to endocarditis, may elicit symptoms which are important in the diag-
nosis. These symptoms consist of pain referable to the heart, symp-
tomatic fever, and excited action of the organ, or palpitation. Symp-
toms relating to the passage of blood through the heart do not belong
properly to the symptomatology of endocarditis, but are due either to
lesions resulting from endocardial inflammation or to accidental
events, such as the formation of coagula. (Flint.)
Pain is very rarely a prominent symptom, and, as in other serous
inflammations, is sometimes altogether absent. Even when it is pres-
ent, it is not easy to refer it to endocarditis, except by taking into
account other symptoms, and especially the physical signs. The pain
is generally dull and obtuse, rarely sharp and lancinating. A feeling
of uneasiness, hardly amounting to pain, is sometimes referred to the
præcordia. The suffering which patients endure from pain in the
joints is so much more severe that they will not be likely to mention
the uneasiness in the heart unless you question them closely. If the
pain in the region of the heart is so severe and acute as to cause com-
plaint, the probabilities are that pleurisy or pericarditis is present,
rather than endocarditis. The fever is not of any importance, for it is
not distinctive of this disease.
Palpitation in endocarditis may arise indirectly from excitation of
the muscular structure of the heart. The action of the heart may be
irregular, as well as unnaturally excited. The pulse may not corre-
spond with the action of the heart, for while the latter may be acting
with increased force, the pulse may be weak. If these symptoms are
observed during the course of acute rheumatism, we may safely sus-
pect the presence of endocarditis, and a careful physical diagnosis
should be made.
Physical Signs of Endocarditis.-Increased extent of dulness
on percussion, due to tumefaction of the heart and accumulation of
blood within its cavities, is considered by many as a physical sign of
DISEASES OF THE ORGANS OF CIRCULATION.
347
endocarditis. Flint, however, doubts whether the cardiac enlarge-
ment often, if ever, exceeds the limit of healthy variations. He thinks
if the heart is enlarged, there must have been a previous hyper-
trophy.
Palpation and Inspection will furnish evidence of excited action.
of the heart. The impulse is seen and felt to be more violent than
in health, or out of proportion to the amount of febrile movement
which exists. But the signs furnished by these methods of explora-
tion will be of little value except as associated with other evidences
of endocardial inflammation.
Auscultation will furnish the only positive proof of the existence
of endocarditis, and this proof is the development of the endocardial
murmur. This association has been substantiated by clinical ex-
perience, and particular attention should be given to its study. In
all cases of acute rheumatism the heart should be first examined and
its condition at the time carefully noted; if the heart is at first normal,
and these changes are set up in a later stage of the disease, endo-
carditis may be confidently asserted. This murmur before referred to
is usually soft, having the character of a bellows' sound. It is systolic,
for it accompanies the first, or systolic, sound of the heart, but it will
not always be found at the commencement of the disease. By some
it is considered even rare in that stage. There are no certain data as
to the period of the inflammation in which this murmur occurs. The
time of its appearance is variable. This murmur is heard at, or near,
the apex of the heart, and may be thus limited. As it is probable
that the anatomical changes rarely involve valvular insufficiency, it is
likely that this mitral murmur does not imply regurgitation from the
ventricle to the auricle. Flint calls it a mitral-systolic murmur, probably
the best name. The presence of this murmur is a sure diagnostic
symptom, if it is in symptoms denoting cardiac inflammation, and if
acute rheumatism coexists.
A murmur developed by endocarditis generally continues not only
throughout the disease, but even afterwards. A mitral murmur may
disappear, however, after recovery from rheumatism, when it was
marked during the disease. This could occur only when the swelling
of the valves diminished, and vegetations were washed away, leaving
the surface smooth.
The cause of this murmur is due to a roughness of the endocardial
membrane, produced by lymph, fibrin, and vegetations.
The heart-sounds themselves may be abnormally altered during endo-
carditis; reduplications have been observed; the first, sometimes the
second, sound may be less distinct than in health, or the first may be
wanting.
It will be found that the diagnosis of endocarditis does not depend
upon symptoms, but almost entirely upon evidence developed by aus-
348
A SYSTEM OF MEDICINE.
cultation, and looking at symptoms alone, this important disease may
be overlooked, and the patient lose the valuable aid which might be
afforded to prevent an organic disease. Consequently, where an or-
ganic trouble of the heart previously existed, endocarditis is apt to
escape notice; and as endocarditis rarely occurs alone, while gener-
ally superinduced by pericarditis, the differential diagnosis should
receive careful attention.
Prognosis. The prognosis of endocarditis is generally favorable,
so far as any immediate danger to life is concerned. The symptoms
may continue and the condition become chronic, causing great in-
convenience, and existing for a long time. Chronic endocarditis may
be suspected if the patient continues to complain of pain and uneasi-
ness at the heart, and if that organ continues unnaturally excited.
But this disease, when chronic, so nearly simulates valvular disease,
that the prognosis depends on the extent of the structural lesion.
Should it lapse from an acute to a chronic state, the prognosis of com-
plete recovery is unfavorable, though death is not always traceable
directly to this condition.
Certain accidental events may occur during endocarditis which may
seriously endanger life, namely: formation of fibrinous coagula; the
detachment of vegetations or of masses of lymph, causing emboli; the
admixture of disintegrated solid deposits; and purulent infection of
the blood.
If we can judge by recorded clinical experience, in many cases of
endocarditis recovery takes place without serious accident. The car-
diac symptoms disappear. The patient, however, is exposed to the
danger of valvular lesions in the future, unless, as far as can be pre-
dicted, the treatment has prevented such a result.
ACUTE ULCERATIVE ENDOCARDITIS.
Synonyms.-Diphtheritic, bacteritic, mycotic, sometimes puerpe-
ral and pyæmic, endocarditis are names applied to this form of in-
flammation of the endocardium.
Definition. It is a distinct form of the disease, in which ulcers
and diphtheritic exudations occur, micrococci are developed, and in
which the blood becomes infected; in fact, there are usually the symp-
toms of severe blood poisoning; and though ulcers may occur in
simple acute endocarditis, this definition is marked enough to estab-
lish a separate name, and as it may be primary and independent, it
also demands separate diagnosis and treatment.
History. The study of this disease has been done chiefly by Ger-
mans, such authors as Sibson and Hayden failing to define sharply,
while Flint, Fothergill, Bartholow, and others, have drawn freely from
the recent investigations of the Germans.
Etiology. The disease seems to demand a peculiar constitution,
DISEASES OF THE ORGANS OF CIRCULATION.
349
a depressed condition of the vital forces, due to bad hygienic influ-
ences," especially in youths, or in men from the age of puberty to
forty. It also, like simple endocarditis, is closely associated with
rheumatism, may develop from simple endocarditis itself, and is often
found in connection with diphtheria, puerperal fever, or may be traced
to an ulcerating wound in some part of the body, especially to wounds
of the female genital organs-post partum.
But "the close analogy between the diphtheritic process and this
ulcerous disease of the left heart, and the frequent coincidence of the
two affections, renders it highly probable that the diphtheritic poison
is the chief factor in its causation." (Bartholow.)
Pathology. The morbid appearances are at first not unlike those
of the ordinary disease-redness, injection of the tissue beneath the
endocardium, red or gray granulations seen in rows or patches-but
the process pursues a different course. The substance of the valve
becomes swollen, soft, lustreless, at places on the edges or surfaces of
the valves the epithelium is removed, the exposed part looks raw,
ulcerous, and these ulcers may burrow, causing perforations or aneu-
risms. Fibrin or white blood-corpuscles may be deposited upon these
granulating surfaces, and when they are washed off by the blood-
current, they form emboli or plugs which produce cerebral or renal
symptoms. The left side of the heart is chiefly affected.
Microscopically examined, these patches of ulcers and granulations
prove to contain micrococci, which have been found at the same time
elsewhere in the body, producing abscesses, and when coming from
the right side of the heart and entering the lungs, suppuration ensues.
The blood generally, becomes impure. Various organs become en-
larged, whether with or without abscesses. Myocarditis and pericar-
ditis may be set up. The valves and chordæ tendineæ may rupture;
and "in the small intestine, swelling of the patches of Peyer and the
solitary glands, and ulcerations which differ from those of typhoid in
that they are not confined to the lower extremity of the ileum, are not
opposite the insertion of the mesentery, and are not limited to the
glands." (Bartholow.)
Symptoms. In all cases of ulcerative endocarditis the symptoms
of the heart and of the endocardium are greatly subordinated to the
general or systemic symptoms; and for this reason it is often over-
looked as a special disease, or confounded with serious lesions of other
parts of the body. There are two types: pyæmic and typhoid.
There is a sudden chill (in the cases of acute rheumatism, during
the puerperal state, or in valvular diseases), pointing to the heart, of
course, and this begins both forms. Following is a high fever, the
intervals being often markedly irregular. In the typhoid type there
follow headache, vertigo, vomiting, slight pain in the præcordia, dry
brownish tongue, constipation, and diarrhoea. Patient sinks rapidly,
350
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A SYSTEM OF MEDICINE.
and in four days is reached the condition seen in the second week of
typhoid. As in typhoid, the abdomen is swollen, tympanitic, and
the spleen is enlarged. Then we have delirium, followed by coma.
The skin may be marked by purple spots. Albuminuria and hæma-
turia set in, and we find involuntary passages of urine and fæces;
there are usually coughs and dyspnoea. On auscultation, a loud sys-
tolic murmur, more marked in the mitral area; patient sinks into a
comatose condition and dies, or dies suddenly through rupture of
valves or chordæ tendineæ.
In the pyæmic type, often chills and fever, which give no relief;
chills, as in pyæmia, being usually irregular. A completely prostrated
condition follows. There may be jaundice, purple spots appear on
the skin, or it may become yellow. Temperature may be 105°, pulse
140. Lungs may be affected; spleen enlarged. Symptoms of the
kidneys, corresponding to those of blood-poisoning. Sudden abscesses
form, painless when at rest. The patient sinks into a comatose state,
and dies. Care should be taken that these general symptoms do not
obscure any that may point to an affection of the heart.
Diagnosis. When present in the course of acute rheumatism,
endocarditis of the typhoid or pyæmic form should, with care, be dis-
tinguished from those diseases, by the history of the case, by study
as the case advances, and as symptoms point more to heart trouble.
In typhoid, the grave symptoms come on slowly, while in endocar-
ditis they advance rapidly, and the latter may be distinguished, too,
by the prolonged rigor and intermissions; but the circumstances in
the case must give the greatest assistance.
Prognosis. The prognosis is always unfavorable, no positive cases
having yet been reported in which recovery from ulcerative endocar-
ditis took place. Death usually results in about ten days, although
in the typhoid form the development may be slower and the crisis
occur at the end of three or four weeks.
Treatment.—There are two objects to be aimed at in the treatment
of endocarditis. (1) To reduce the inflammation as quickly as pos-
sible in order that the valves may not be seriously injured, and (2) to
prevent that loss of power in the heart-muscle which may lead to
cardiac failure. I cannot agree with some authorities who assert that
failure of the cardiac muscle begins with the disease. My observation
is that such is not the case in acute endocarditis, unless occurring in
cachectic subjects, or due to blood-poisoning, as in Bright's disease,
pyæmia, or scarlatina. In idiopathic, or acute, rheumatic endocar-
ditis, the first stage is characterized by an action of the heart, in which
there are excessive force and increased blood-pressure. This can be
seen in the hard pulse, the increased impulse of the heart, the arterial
turgescence of the head, and other equally prominent symptoms.
The medicines most appropriate for the first, or acute, stage are:
DISEASES OF THE ORGANS OF CIRCULATION.
351
Aconite, Veratrum viride, Belladonna, Bryonia, Convallaria, Digitalis,
Cimicifuga, and Spigelia.
Aconite, in its pathogenetic and pathological action, probably presents the near-
est similimum to endocarditis. It is needless to give all the symptoms which may indi-
cate it. The most prominent and characteristic are: the general febrile state, the
high temperature, the acute pain with swelling of the joints, the great restlessness
and anxiety, the fear of death, the small, hard pulse, which does not always accord
with the action of the heart, i. e., the heart may be beating violently, and twice as
often as the pulse. It is indicated when endocarditis is complicated with pericarditis,
and when the stasis of the lungs is very marked. Its use should not be continued too
long, but it should give place to some other remedy when the temperature is lowered
to 100° F., and the action of the pulse and heart is modified.
Veratrum viride is equally important with Aconite, but the indications are
quite different. The action of the heart is more violent, more forcible in its stroke.
upon the wall of the chest. The blood-pressure is stronger, the temperature higher,
the pulse always large, hard, bounding, and unyielding, and this intense impulse is
noticeable in the temporal arteries. It is better adapted to idiopathic endocarditis
than Aconite. There are no distinctive symptoms of the chest which indicate it, for
all remedies have the dyspnoea and oppression. As Veratrum viride is our greatest
remedy in acute congestion of the lungs, so in endocarditis is it a powerful agent to
prevent such a complication. Some cases of endocarditis are ushered in by a violent
congestion of the brain and medulla that often masks the cardiac trouble. Here
Veratrum viride, if given boldly, is certain to prevent serious injury to the cerebro-
spinal centres. Like Aconite, it should not be continued too long. So soon as the
pulse becomes softer, and the temperature lowers, it should be given at longer inter-
vals, or discontinued. A quick pulse is not necessary to indicate this drug. I have
lately treated two cases in which the pulse was 40 to 50, while the heart beat was 70
to 80, but the great volume and hardness of the pulse induced me to give Veratrum
viride. While I find Aconite adequate in the lower dilutions (1 to 3), I give Verat-
rum viride in doses of 1 or 2 drops of the mother tincture, or of the first decimal attenua-
tion, nor do I think it should be given higher if we desire its prompt curative action in
this disease.
Cactus grandiflora may be imperatively called for when we have the sen-
sation as of an iron band constricting the heart, with great anguish, dyspnoea, etc.
It is indicated when, preceding or attending these symptoms, there is great pain in the
occiput.
Bryonia, although supposed to be more useful in pericarditis, is certainly as
often indicated in endocarditis. It corresponds perfectly to those varieties of acute
rheumatism which are associated with inflammation of the endocardium. This mem-
brane is structurally a serous membrane, and Bryonia has a specific affinity for it,
causing in all serous membranes an inflammation resulting in effusion of serum,
plastic lymph, or vegetations. No remedy is, therefore, more homoeopathic to valvu-
litis with vegetations or thickening. The absence of the peculiar "sticking" or
"stitching" pains is not a contraindication, for it has been shown that even acute
pleuritis may run its course without these pains, and so may pericarditis. It is the
pathological condition of the patient and the concomitant symptoms, which should
guide us in the selection of Bryonia. As swelling and vegetations on the valves
occur very soon in the course of endocarditis, it is not always best to wait until Aconite
or Veratrum viride are no longer indicated, but we may alternate Bryonia with one
of them. A strict adherence to the dictum of non-alternation will be to lose valuable
time. Bryonia has high fever, a very intense frontal or occipital headache, aggrava-
tion of the pain on slightest movement, dyspnoea, and valvular murmurs. These,
and the character of the attending or preceding rheumatism, must be the indications
for Bryonia.
Belladonna is an excellent remedy in acute pericarditis. It closely resembles
Veratrum viride in the appearance of its symptoms. It has throbbing of the cerebral
arteries, violent action of the heart, a hard pulse, engorgement of the capillary system,
intense headache with delirium or sopor, aching in the cardiac region, taking one's
breath away and causing anxiety, occasional intermittence of the pulse, injection of
the conjunctiva, and, often, dilated pupils.
Digitalis may be homeopathic to endocarditis, but some explanation of its ac-
tion may be necessary in order to understand when it is indicated. The primary
352
A SYSTEM OF MEDICINE.
action of Digitalis, in large doses, is to quicken and intensify the action of the heart,
increasing the force of its contractions and the pressure of the blood in the arteries.
This increased force may go on until the ventricles are thrown into spasms of such
tetanic nature as to arrest the heart in systole and to cause death. In this extreme
condition the contractions of the ventricles become short and abrupt, rendering the
pulse feeble and irregular, in fact, the same kind of a pulse which exists when the
heart is feeble, and its muscle on the point of paralysis. But the condition of the
heart, during the primary action of Digitalis, is the opposite of that which occurs
during its secondary action The opposite school consider Digitalis only a cardiac
tonic, and declare it contraindicated in conditions of increased blood-pressure, as in
concentric hypertrophy and inflammation. Homoeopathists, however, can use it with
benefit during the acute stage of endo- and pericarditis, when the condition above
mentioned, of spasmodic but incomplete contraction, is present, with the feeble irreg-
ular pulse. It is not indicated in the acute, but rather subacute, endocarditis, or, after
the acute stage has subsided, and is followed by, or complicated with, spasm of the mus-
cular walls of the heart. Other symptoms indicating Digitalis are: vomiting, ver-
tigo, delirium, abnormal vision, rapidly increasing dyspnoea, spasmodic cough, with
expectoration mixed (not striated) with blood, livid turgescent face, cannot lie down
or be moved without anguish from dyspnoea. The dose must be small, not lower than
the 2* dilution, for larger quantities will cause intense aggravation when thus primarily
indicated.
Convallaria (Lily of the Valley), one of the several new cardiac drugs, closely
resembles Digitalis in its action. It is not supposed, however, to have such an intense
primary action on the heart's muscle, but seems to have a greater affinity for the pneu-
mogastric. It is indicated in acute endocarditis when the temperature has fallen, but
the heart is acting too strongly, and there are present intense nervous erethism and
dyspnoea, out of proportion to the severity of the cardiac disease. The dose should
be the same as of Digitalis. (The tincture or fluid extract of the flowers should always
be used.)
I shall only mention two other remedies for the first stage of endocarditis, namely,
Cimicifuga and Spigelia. They are also indicated in the later stages, for they correspond
to that condition of the heart known to be frequently associated with chorea. Dr. Fagge
and Sibson, in Reynolds's System of Medicine, consider chorea, next to acute rheumatism,
in its power to cause endocarditis and valvular disease. The peculiar pathological
lesion, occurring in chronic endocarditis, is said to be "a row of minute granulations
on the edges of the valves." But as acute rheumatism and chorea are often combined
in the same case, it is difficult to separate the two kinds of endocarditis.
Cimicifuga is one of our most potent remedies in acute rheumatism, as well as
for chorea. It is not so much the high temperature in acute inflammation which in-
dicates this drug, as the violent pain in the large muscles. I have always believed it
more adapted to myocarditis than to endocarditis, but we rarely find a case of the
former unconnected with the latter. If, with chorea, or intense muscular rheumatism,
with violent aching pains in the parts affected, we have intense frontal headache, or
headache as if the top of the head would be lifted off (a gloomy mood); severe ach-
ing in the eyes, pain in the left side, under the nipple, and down the left arm; and
if the attack has come on after suppressed menses, Cimicifuga, in the lower dilutions,
has always done me good service.
Spigelia, in its symptomatology, gives a perfect picture of chorea of the heart.
It has "undulating motion of the heart, indistinct beats of the heart running into one
another, tumultuous beating of the heart when sitting or lying, not synchronous with
the radial pulse; spasms of the chest, suffocative attacks; trembling in the heart, great
dyspnoea on the slightest motion; the impulse of the heart is violent and feeble by
turns; purring murmur in the heart," etc. These symptoms often persist after the
acute endocardial inflammation has passed away, showing how persistent is the chronic
irritation. In these cases no remedy can rival Spigelia, and many brilliant cures
are recorded from its use.
External applications are not without value in endocarditis.
Rejecting absolutely the absurd and barbarous "anti-pyretic "measures
taught by Ziemssen and the German school, I recommend warm poul-
tices of flax-seed meal, or raw cotton. The chest must be kept warm,
so that the cutaneous blood vessels may be full, in order to keep as
DISEASES OF THE ORGANS OF CIRCULATION.
353
much blood as possible from the heart. When there is great pain and
distress in the cardiac region, a lotion of aconite, chloroform, and oil
or vaseline should be rubbed upon the chest, and the cotton wool ap-
plied over it.
Rest is absolutely necessary, not only in the first stage of endocar-
ditis, but in the later stages as well. Every motion of the body, es-
pecially if made by the patient, increases the anxiety and palpitation,
and taxes the already overburthened heart to the utmost. Urination
and defecation should be performed in the lying posture. When the
patient's position must be changed, the change should be made by
the nurses. When the powers of the heart begin to fail, these rules
are imperative, for a large proportion of all the deaths during this
disease have been caused by changes of position, such as sitting up or
suddenly turning over in bed.
In the second stage of endocarditis, when the cardiac muscle begins
to fail, and the swollen or obstructing valve impedes the free flow of
the blood-current, the treatment should be changed. Such remedies as
Aconite and Veratrum vir. are rarely indicated, especially in appre-
ciable doses. If given at all, the high potencies must be used (from
the 6th to the 30th). The extreme primary pathogenetic action of
these two drugs is to reduce to a minimum the vital power of the heart.
Aconite is indicated when the patient is slowly sinking; the pulse is small and
thready, the heart's impulse is almost imperceptible, only a fluttering; the skin is cold
and clammy, and the patient is anxious, and his intelligence clear. Here, according
to strict homœopathic indications, Aconite ought to rally the sinking vitality. In some
instances I have known it to act favorably.
Veratrum viride has widely different symptoms. The pulse sinks to 25 or
30 per minute, but remains full and large, but very soft, so soft, indeed, as to afford no
resistance to the finger; the beats of the heart are the same, or in some instances
double, two pulsations being required for the half-paralyzed ventricle to send the
sluggish current to the wrist. But in these cases of cardiac failure, especially if rapid,
I prefer to trust to medicines which are secondarily indicated, i. e., those which cause
cardiac paralysis by their secondary effects. These remedies are Digitalis, Convallaria,
Adonis, and Amyl nitrite.
Digitalis is indicated by a rapid, regular, feeble pulse, an irregular, feeble pulse,
or a feeble, slow, and intermittent pulse. With this pulse, the heart may appear to
beat violently, but it is action without force, and will end in failure unless given in-
creased tonicity. Digitalis is here our sheet anchor; but it must be given boldly,
not in the dilutions, but in large doses of 5, 10, or 15 drops of the tincture every hour
until the pulse and the general condition of the patient show that he is out of im-
mediate danger. In sudden and alarming cases, Digitaline should be injected hypo-
dermatically, ro or of a grain every hour until improvement sets in. At the same
time, the patient should not be allowed to make the slightest movement, not even to
raise the head to take liquids from a spoon. The body and limbs should be gently
rubbed with spirits or, better, Ammonia-water. In desperate cases, Ammonia or
Ether should be used by hypodermic injection. In several cases which I have on
record, I am satisfied that life was saved by the administration of Aromatic Ammonia
and Digitalis, fifteen drops of the former to five of the latter, in a spoonful of milk or
sweetened water-every half hour till reaction occurred.
Amyl nitrite will rally the failing heart almost instantaneously, almost bringing
the patient from death, but it cannot be relied upon unless aided by Digitalis and
stimulants.
Convallaria rivals Digitalis in its power to impart strength to a failing heart.
I have used it successfully in desperate cases when Digitalis was not well borne, or
VOL. I.-23
Dorm
354
A SYSTEM OF MEDICINE.
failed to exert its usual power. Besides the symptoms given under Digitalis, Con-
vallaria is indicated by the intense orthopnoea, a dyspnoea which is terrible in its
manifestations. The dose is the same as for Digitalis.
Adonis, in the hands of French and Russian physicians, is credited to possess
properties equal to Digitalis and Convallaria, and Casca (Erythrophleum) has similar
power as a cardiac tonic.
Caffeine, in doses of one to three grains, will often bring back the failing power
of the heart, as I have on many occasions verified.
Quinine should never be used for this purpose, for it is a vaso-motor paralyzer,
and its action in appreciable doses would be fatal. There is only one condition when
it could be useful, namely: when the heart failure is periodic, intermittent, and due
to malaria; and then it should be given only in the apyrexia and in moderate doses.
I mention this dangerous quality of Quinine because I have known of several deaths
caused by its use when given recklessly by allopathists in cases of endocarditis.
When endocarditis is due to the absorption of poisonous matters,-
as in pyæmia, Bright's disease, diphtheria, or scarlatina,-those reme-
dies which induce a similar toxic condition of the blood should, if
possible, be selected. At the same time we should direct our endeavors
to the object of eliminating such poisonous products of disease from
the blood of the patient.
The chief remedies for this form of endocarditis are Arsenic, Lache-
sis, Naja, Crotalus, Phosphorus, and the Cyanuret of Mercury.
Arsenic is chiefly useful in this form, not so much for its power over the inflam-
mation of the endocardium, as for its powerful action as an antidote to septic poisoning,
and its homœopathicity to toxic paralysis of the cardiac muscle. It corresponds also
to the rapid serous infiltration of the endocardium. It has a feeble, irregular pulse,
slow or quick, great anguish and restlessness, cachectic appearance, cool pale skin, often
bathed in cold sweat, orthopnoea, great thirst, etc.
Lachesis corresponds more closely than Arsenic to toxic or septic endocarditis.
In persons poisoned by snake venom the integrity of the blood is soon destroyed —all
the secretions become septic in character, and violent inflammation of the heart occurs,
runs a rapid course and ends suddenly in cardiac paralysis.
Crotalus comes next to Lachesis in virulence, and Naja is closely allied. For
the differential diagnosis of these serpent poisons the practitioner must refer to the
Materia Medica.
Phosphorus is closely allied to Arsenic. It corresponds more closely to com-
bined nephritic and cardiac inflammation than any other remedy, also to those cases
due to absorption of poisonous excrementitious matters-the products of malignant
diseases. Again, when the cardiac inflammation is complicated with pneumonia,
Phosphorus is indispensable; not so much in the acute stage, as when the disease as-
sumes a nervous or typhoid character, and the vital forces are fast failing. It is hom-
œopathic to that tendency to rapid dilatation which often rapidly develops itself during
endocarditis.
Mercurius cyanuretum ought to be the best remedy for diphtheritic or
ulcerative endocarditis, but we have no clinical experience to offer. Its symptoms have
a remarkable resemblance to rapid heart-failure due to malignant cardiac disease.
The treatment of the consequences of endocarditis will be found
under valvular diseases, dilatation, myocarditis, etc. I have pur-
posely confined myself to the acute disease. I do not recognize
chronic endocarditis, for all its manifestations, as described by various
authors, should be classed under valvular diseases and other sequel
of acute endocarditis.
DISEASES OF THE ORGANS OF CIRCULATION.
355
VALVULAR DISEASES OF THE HEART.
GENERAL CONSIDERATIONS.
Diseases of the valves of the heart are of peculiar importance, not
so much on account of the local disorder itself, as on account of the
secondary troubles which are likely to appear in remote organs and
which often lead to a fatal termination.
These troubles arise from the disturbed equilibrium of the circula-
tion, which results from the faulty action of the valves. They are
mostly congestive troubles, as bronchitis and emphysema, cerebral
hyperæmia and apoplexy, chronic nephritis, and engorgement of the
liver, etc.
Valvular diseases are also important because of their frequency, and
on account of the effects of judicious treatment upon them. Their
course is chronic and invariably progressive, unless arrested by pro-
per hygienic and remedial measures. They do not recover sponta-
neously, but careful watching and skillful treatment will often keep
them in check for years.
Any one of the four valves may become the seat of this affection;
the greater liability lies with the valves of the left side of the heart, and
most frequently it is the mitral or bicuspid valve that suffers.
The aortic valves are second in frequency of affection; the tricuspid
and pulmonary valves are rarely involved.
The valves of the right side of the heart become primarily diseased
in early life, and frequently before birth. Should, from any cause, an
endocarditis begin during intra-uterine life, or shortly after birth, the
affection is invariably limited to the right side of the heart, and
consequently gives rise to stenosis or insufficiency of the valves of the
same side. Valvular disease in children is almost always limited to
the tricuspid and pulmonary semilunar valves, and, through imper-
fect compensation, usually destroys life at an early age. The expla-
nation of this fact is found in the peculiarities of the foetal circu-
lation.
Physiologists teach that during foetal life the blood from the ascend-
ing vena cava passes at once from the right auricle through the fora-
men ovale into the left auricle, without the formality of entering the
right ventricle and the lungs. From the left auricle it passes into the
left ventricle, and hence into the aorta and the systemic circulation.
The blood from the descending vena cava pursues a different course.
It passes from the right auricle to the right ventricle, and hence through
the pulmonary artery and the ductus arteriosus into the systemic cir-
culation. During this period the right side of the heart has more
work to do than after birth, there is greater pressure put upon it, and
356
A SYSTEM OF MEDICINE.
this seems to determine the location of any inflammatory process that
may arise.
It is not impossible for the right side of the heart to become diseased
in adult life, but the cause of the increased blood-pressure must in
such a case be sought for in some abnormal condition of the pulmon-
ary circulation, usually due to mitral or aortic disease.
The majority of cases of valvular disease in adults are secondary to
acute endocarditis, and this affection, in turn, is usually a complica-
tion of rheumatism, so that acute inflammatory rheumatism is, of all
causes of serious diseases of the heart, by far the most prolific.
Other troubles, however, may excite an endocarditis, as, for exam-
ple, the acute infectious diseases, pyæmia, puerperal fever, and diph-
theria, and some chronic affections, such as nephritis, syphilis, alcohol-
ism, atheroma, and, occasionally, violent muscular efforts. The latter
factor is more apt to cause a rupture either of the chordæ tendineæ or
of the valves, than to excite an inflammation of the endocardium.
Lesions of the valves are of two kinds, namely, obstructive and re-
gurgitant. Sometimes the two conditions are found in the same valves,
but it must be remembered that all diseases of the valves come under
one head or the other.
The pathological condition in obstructive lesions, or stenosis, is one
of thickening of the free borders of the valves, resulting most often.
from acute endocarditis.
This inflammatory process is most intense at the free border of the
valves, probably because of their constant activity. In other situa-
tions motion aggravates an inflammation, and there is no reason why
it should not do so in the heart. The valves are moving back and
forth seventy times a minute during health; should inflammation
begin in one of them, is it not reasonable to presume that the constant
motion and effort to which it is subjected would increase the inflam-
mation very materially?
During the inflammatory process there is some swelling of the
valves, and after the acute stage has subsided, more or less hyperpla-
sia of the tissues remains.
The thickened valves are not able then to open as fully as in health,
and consequently offer more or less resistance to the blood-current. In
some cases the thickening is so great, and the segements become so
glued together, as only to leave an opening of the size of a quill or of
a bristle.
Other changes are very likely to take place at a later period, usually
of a degenerative nature.
In aged persons who suffer from endarteriïtis and atheroma, athe-
romatous patches are apt to occur on the surface of the valve (aortic
usually). These patches weaken the valve-segment, and cause a
bulging which is called a valvular aneurism. Should this aneurism.
DISEASES OF THE ORGANS OF CIRCULATION.
357
burst, insufficiency of the valve and regurgitation of the blood imme-
diately occur.
In a large proportion of the cases, vegetations spring up from the dis-
eased valve. They are usually multiple, and by their rubbing against
the heart-substance, or the walls of the large vessels, as the case may
be, they are apt not only to cause irritation, but also to give rise to
small vegetations at the points of contact.
The vegetations in time undergo calcareous degeneration, as does
also the thickened valve; this chalky deposit may be so extensive as
to form a firm “bony" ring around the valvular orifice, which is in-
capable of variation. It is remarkable that life can be maintained
for a considerable period of time under such circumstances.
The pathological changes in insufficiency of the valves are practi-
cally the same changes which occur in connection with obstructive
lesions, with only this difference, that in the former condition the
edges of the valves retract, and hence complete closure of the orifice
is rendered impossible.
A valve may be rendered insufficient without giving evidence of
derangement in its own structure; under such circumstances the in-
sufficiency depends upon some abnormal state of the heart-wall.
If, for instance, for some reason, the left ventricle should become
dilated, while the mitral valve remained in perfect condition, the di-
latation of the ventricle might be carried so far as to separate the
attachments of the two segments of the mitral valve and prevent their
free borders from coming in contact with one another; the blood
would then be permitted to flow back into the left auricle during the
ventricular systole.
Insufficiency, therefore, may occur in a perfectly healthy valve;
stenosis, on the other hand, is always due to some abnormal condition
of the valve itself.
When the two conditions are combined, the obstruction makes its.
appearance first. The hyperplasia is considerable, and at a later
period this new tissue contracts, drawing with it the free border of the
valve, and insufficiency results.
Valvular diseases, whether obstructive or regurgitant, give rise to
secondary nutritive changes in the heart muscle. They are conserva-
tive changes on the part of nature, who makes an effort, more or less
successful, to compensate for the results of the abnormal condition of
the valves.
The first effect of a valvular lesion, be it obstructive or regurgitant,
is to put a greater amount of work on the heart. This increased effort
calls for increased strength, and this causes increased thickness of that
portion of the heart upon which the extra labor is put. In other words,
the wall becomes hypertrophied, and this condition is recognized as
a "compensatory" hypertrophy. So long as it is possible in this
358
A SYSTEM OF MEDICINE.
manner to supply the system with the normal amount of blood, the
circulatory equilibrium is sustained, and there are no subjective symp-
toms of disease.
This condition may be maintained for years, and not cause incon-
venience to the patient. As a rule, lesions of the aortic and mitral
valves are well compensated for, while those of the pulmonic and tri-
cuspid valves are not. The reason for this lies in the fact that the
aortic valve has all the cavities of the heart to back it. Yet there is
one lesion of this valve, insufficiency, that comes to an early end. In-
sufficiency of the mitral valve is compensated by the right side of the
heart and the left auricle, while the pulmonic is sustained by the right
ventricle and auricle, and the tricuspid simply by the right auricle.
Should, in any case, a cavity of the heart be over-filled with blood,
as is the case in regurgitation, it dilates; at the same time the walls
may undergo hypertrophy. But if, at a later period, the circulation
in the coronary arteries should be interfered with, the hypertrophic
condition would soon disappear, and simple dilatation would be the
result. As soon as the dilatation begins to predominate over the hy-
pertrophy, the equilibrium of the circulation would be destroyed, and
symptoms of disease necessarily show themselves.
Symptoms. The symptoms caused by valvular lesions are the
effects of the disturbance of the circulation rather than of the diseased
condition of the heart itself. In all valvular troubles the arteries are
robbed of the normal amount of blood, while the veins are over-filled.
This venous congestion soon produces changes in the organs of the
body which interfere with a proper performance of their functions,
render the patient more or less miserable, and often are the immediate
cause of death.
Lungs.-Diseases of the aortic and mitral valves produce, primarily,
an engorgement of the left auricle, and then of the pulmonary vessels.
Pulmonary congestion gives rise to chronic bronchial catarrh, with the
excessive secretion of mucus. This condition necessarily induces an
obstinate and distressing cough, which is not relieved by expectora-
tion, as most lung troubles are. Sometimes the congestion is so great
that capillaries are ruptured and hæmorrhage into the alveoli occurs.
Often the sputum is blood-streaked.
This condition also favors the development of pulmonary œdema
in advanced cases, which often proves the immediate cause of death.
Under all circumstances, breathing is rendered very difficult; some-
times the dyspnoea is so great that the patient cannot lie down with-
out almost suffocating; the sufferer is obliged to sit up nearly all the
time; he sleeps in the erect posture, or, rather, stooping over, with hist
arms resting on some support in front of him; this condition is called
orthopnoea.
Liver. The liver, at an early stage, suffers from the general venous
DISEASES OF THE ORGANS OF CIRCULATION.
359
congestion. The increased amount of blood which the vessels are
obliged to hold enlarges the organ considerably, and, in the course of
time, gives rise to the pathological condition known as the "nutmeg
liver." On section, the organ presents a mottled appearance which is
due to engorgement of the inter-lobular veins (the radicles of the
hepatic veins) and to a lighter zone around the periphery of the
lobules. At a late stage of the disease the liver becomes shrunken
and smaller than normal; this is probably due to atrophy of the
hepatic cells. Of course, the symptoms of chronic congestion of the
liver are present. The patients are liable to be more or less jaundiced,
and to suffer from catarrh of the bile-ducts. When the organ is atro-
phied, ascites may result, as in cirrhosis.
Kidneys. The kidneys soon feel the effects of cardiac trouble.
The first change is in the circulation, consisting in a diminished
quantity of arterial blood. As a consequence of this diminished
supply, the urine becomes scanty and heavily loaded with the excre-
mentitious salts. The relative amount of urea and of the urates is in-
creased, and they usually form a heavy deposit as soon as the urine
cools.
Combined with the lessened quantity of arterial blood, at a later
period, there is venous engorgement which favors the transudation of
serum from the capillaries into the tubules, and gives rise to albumen
in the urine.
The kidneys are not apt to undergo any change of structure, but
the congestion changes the appearance of the organs in a characteristic
way. They become swollen and very firm, almost hard to the touch.
The cortical substance, but more especially the medullary portion,
takes on a dark bluish-red color which has suggested the name of the
"cyanotic kidney." When examined microscopically, no change is
found, as a rule, but sometimes there is increase of the connective
tissue with degeneration of the epithelium-the cirrhotic kidney.
Brain. The brain does not escape disturbance when the blood be-
comes dammed in the venous system. Passive congestion of this
organ must occur, and it is accompanied in the later stages by oedema.
The serum transudes and fills the ventricles, the cerebro-spinal fluid
is increased, and chronic hydrocephalus results. The symptoms ac-
companying these conditions are: a tendency to vertigo and mental
dulness; the patients are irritable and capricious; they are despond-
ent and melancholy, but have not the mental anxiety concerning their
condition which accompanies functional heart troubles.
In aged persons the blood vessels of the brain are apt to become
atheromatous, this condition giving rise to hemorrhages and apo-
plexy. This is particularly liable to occur when the left ventricle is
hypertrophied.
The occurrence of an embolus constitutes one of the most serious
360
A SYSTEM OF MEDICINE.
accidents to the brain. A clot becoming detached from a vegetation,
and entering the circulation, is very apt to pass into the left common
carotid, and from there to find its way into the left middle cerebral
artery, and to lodge in one of its ramifications. Such an event is
characterized by a "stroke." The patient is stricken suddenly with
unconsciousness, and as his senses return he finds that the right side
of his body is paralyzed, and that he cannot speak.
Aphasia and hemiplegia of the right side result in typical cases of
embolism, but there are occasionally atypical cases in which there is.
not unconsciousness, and only paralysis of certain muscles, or in which
the loss of speech is the only sign of trouble.
The embolus shuts off the circulation to a limited area of the brain
tissue, and unless collateral circulation is speedily established, soften-
ing and disintegration ensue. This event renders the paralysis per-
manent, so that, although the condition may in time grow better than
immediately after the stroke, the entire use of the muscles is never
regained.
Delirium sometimes occurs and is an unfavorable omen. Horrible
dreams commonly disturb the little rest which the patient is able to
get.
Dropsy. The mechanical obstruction to the circulation and the
accumulation of blood in the veins lead to dropsy. The increase of
the blood-pressure favors the escape of the serum into the loose and
yielding areolar tissues of the body, and dropsy occurs as soon as the
pressure exceeds that exerted by the tissues. The first symptom of
dropsy is a slight puffiness about the ankles at night, which disap-
pears before morning. The dropsy occurs first in the most dependent
portions of the body, but sooner or later becomes more extended, and
in mitral and tricuspid diseases is liable to become general.
Ascites from obstruction to the portal circulation is common and
may be great in amount. All the serous cavities contain serum when
the dropsy becomes general, and we find hydropericardium, hydro-
thorax, ascites, as has been mentioned, and effusion into the ventri-
cles.
The dropsical condition is likely to be a source of great distress to
the patient. If the chest contains much fluid, breathing is interfered
with, and may lead to a fatal termination. A large amount of fluid
in the abdominal cavity may also interfere with breathing when the
patient is on his back, by pressing on the diaphragm. The weight
and the feeling of distension of the skin are painful when the oedema is
great. Unfortunately, this condition cannot be cured. The processes
under which the dropsy first developed, continue, and though the
fluids in the tissues may be temporarily removed by medicinal and
surgical measures, the relief is only temporary, the fluids again accu-
mulating, and in larger quantities than at first.
DISEASES OF THE ORGANS OF CIRCULATION.
361
The skin, in these affections, has a peculiar livid hue which dis-
tinguishes it from renal disease accompanied by dropsy. This is
probably due to the fact that in the former class of cases the blood
does not undergo such a profound change as in the latter; it does not
become hydræmic.
Nature tries to relieve herself of the venous engorgement through
the natural channels; thus it is that there is occasionally observed a
serous diarrhoea, and usually increased secretions from other mucous
surfaces; but these efforts are defective and unable to afford much
relief.
LESIONS OF THE AORTIC VALVES.
Aortic Stenosis.
Ætiology and Pathology.-Aortic obstruction is not commonly
a result of acute endocarditis, but is more likely to be seen in aged
persons who are subject to endarteriitis and atheromatous changes in
the aorta. The morbid condition is apt to involve the aortic valves,
giving rise to atheromatous patches on the surface of the segments.
Atheromatous ulcers are a frequent cause of aneurism and rupture of
these valves.
One or two segments may be the seat of disease, but usually all of
them are involved.
Acute rheumatic endocarditis is also a cause of aortic stenosis, but
not commonly; this affection is more apt to limit itself to the mitral
valve.
The ventricular surface of the aortic valves is a favorite place for
vegetations to spring up. They may be single or multiple, and are
prone to undergo calcareous degeneration. It is at this orifice that the
"calcareous rings" are usually found. This condition was formerly
called "ossification" of the valve, but microscopical and chemical
tests prove it to be simply the deposit of calcareous particles in the
substance of the valves and vegetations.
The rough surface caused by the vegetations favors the formation of
fibrin, and oftentimes a clot of fibrin, clinging to the surface of the
valve, has been mistaken for a vegetation. It is well at post-mortem
examinations to examine all excrescences very carefully, in order to
distinguish between a veritable outgrowth of tissue and fibrin. Frag-
ments of these clots clinging to the roughened valves may become
broken and be swept by the blood-current to remote organs, where
they lodge and form emboli.
Aortic obstruction is the best compensated of all valvular lesions.
The powerful left ventricle becomes hypertrophied sufficiently to
force the blood past the obstruction. As there is not an increased
amount of blood in the cavity of the ventricle, it does not dilate, but
remains simply hypertrophied. Even when the obstruction is very
362
A SYSTEM OF MEDICINE.
great, the equilibrium is maintained, and no subjective symptoms are
experienced. This condition of affairs may last for years, and the
patient never know he has heart disease. But in old persons, and in
the atheromatous condition, the affection may lead to regurgitation, or
extend to the mitral valve, and there cause serious trouble.
Diagnosis. The diagnosis of aortic stenosis is made solely on the
physical examination.
Inspection reveals the action peculiar to hypertrophy of the left
ventricle, the heaving of the chest over the heart from the powerful
blow caused during the ventricular contraction. The heart is some-
what enlarged, owing to the thickening of the ventricular wall, and
consequently the area of cardiac dulness is increased in proportion.
The apex is also displaced to the left and downward.
Auscultation is the positive means to a diagnosis. A murmur is
heard most distinctly over the aortic valves, that is, at the right border
of the sternum in the second intercostal space. The murmur is rather
loud, rough or musical in character, and is systolic, thus masking
somewhat the first sound of the heart-beat and extending to the second
sound, which in its turn is rather faint.
The murmur is quite distinct, and has the characteristic that it can
be traced along the arteries for some distance. Thus it can be heard
over the subclavian, the carotids, etc. Care must be taken to differ-
entiate between the anæmic murmurs and the "venous hum," which
are also encountered in this location.
Anæmic murmurs are louder in the neck than at the heart, and are
sometimes so harsh as to be called le bruit du diable. They are always
accompanied by an anæmic condition of the patient, and are usually
noticed in young girls.
The pulse undergoes a marked change. The difficulty with which
the blood is forced through the aortic orifice makes the pulse slow in
developing, as is shown by the sphygmograph. At the same time it
is hard, regular, and incompressible.
Prognosis. This lesion, if uncomplicated, is as a rule thoroughly
balanced by the ventricular hypertrophy. If the orifice be very
small, however, cerebral anæmia is apt to occur, accompanied in some
cases by apoplexy or syncope, and sudden death may take place from
dilatation of the ventricle and paralysis of the heart from this over-
distension.
Aortic Regurgitation.
Etiology. This disease often accompanies aortic stenosis. The
processes that give rise to the latter may reach a point where the
valves are rendered insufficient, and then the signs and symptoms of
this condition appear.
One of the most frequent causes of aortic regurgitation is violent
DISEASES OF THE ORGANS OF CIRCULATION.
363
muscular exertion, particularly of the arms and chest. It is a well-
known fact that athletes, oarsmen particularly, are subject to heart
disease, and this is the form to which they are liable. Blacksmiths,
miners, and all laborers who use the arms excessively are liable to
suffer in the same way.
It is interesting to study the development of the disease in these
cases. Fothergill says on this subject: "The exciting cause of the
low interstitial inflammation, with growth of connective tissue, is
essentially the violence with which these valves are closed, or rather
driven together, by the backward rush of blood on the aortic recoil.
When, then, recoil is increased, so is the force with which these valves
are closed."
In persons who tax their arms to the utmost, oarsmen, etc., during
the period of exertion, the heart's action is very violent, and the
blood is forced into the arterial circulation in greater quantities than
during repose. At the same time the active muscles offer marked
resistance to the circulation by powerfully contracting, and thus the
larger vessels become engorged, and the increased blood-pressure, with
the increased force of the aortic recoil, in time have an effect upon the
valves.
Compensation.-The circulatory equilibrium may be established
by compensatory dilatation and hypertrophy of the left ventricle.
The cavity dilates from the increased quantity of blood which comes
to it from the auricle and also from the aorta. This satisfactory con-
dition cannot be maintained for any great length of time, as is the
case in aortic obstruction, because the circulation in the coronary
arteries is interfered with, and sooner or later the muscles degenerate,
and then dilatation predominates over the hypertrophy. When this
time comes, things go from bad to worse, the dilatation increases,
sometimes to an enormous extent, the mitral valve may be involved,
and the effects of the impeded circulation are shown in general venous
congestion.
The character of the pulse is changed, and acquires peculiarities
which suggest at once the nature of the trouble. In the first place,
the increased power of the ventricular contraction forces the blood
into the arteries with a bound, but during diastole the blood regurgi-
tates and the arteries collapse. The impression conveyed to the finger
at the pulse is like a ball rolling by in the artery. This peculiarity
was first pointed out by Dr. Corrigan, of England, and is termed
"Corrigan's pulse." Sometimes the disease is called Corrigan's dis-
ease by English writers, but more commonly it goes by its anatomico-
pathological name.
The powerful ventricular contraction causes the arteries to pulsate
visibly in nearly every superficial point of the body, and they can be
distinctly felt even to the smallest arterioles. The Germans use this
364
1
A SYSTEM OF MEDICINE.
as one of the means of diagnosis, and search for the peculiar pulse at
the anterior tibial and dorsalis pedis arteries. This condition is most
marked during the early period. Later, when dilatation predomi-
nates, the heart's action grows weaker, and the peculiar shot-like feel-
ing of the pulse is not distinct.
Diagnosis. The diagnosis, like that of all other cardiac affections,
depends upon the physical examination.
Inspection shows the existence of the conditions observed in aortic
obstruction, the bulging of the chest over the heart, and the heaving
impulse given to the chest with every heart-beat. But the one char-
acteristic feature of the disease is the visible pulsation of the superficial
arteries. Whenever this is seen, aortic regurgitation is more than
probable. Palpation is merely serviceable in recognizing the peculiar
shot-like feeling of the pulse. Percussion reveals enlargement of the
heart and consequent displacement of the apex. If the enlargement
is very great, the lower end of the organ may be found as low as the
seventh intercostal space, and the left border an inch or more to the
left of the nipple.
In this disease auscultation furnishes most valuable indications.
Where there is simple regurgitation without obstruction, a regurgitant
murmur takes the place of, and follows, the second sound of the heart-
beat. The ventricular systole is heard distinctly at the apex, but may
be less pronounced than in health, and there is no abnormal sound
until the aortic valves close. Then the regurgitant murmur appears
and lasts during the greater part of the diastole; it is most distinct at
the right border of the sternum in the second intercostal space. It
cannot be traced along the course of the arteries of the neck, but may
be heard at the apex of the heart, and sometimes may be traced for
some distance to the left. In this respect it resembles the mitral
regurgitant murmurs, for which it may be readily mistaken; but if
care is taken to note the time when the murmur appears, and the
point at which it is most distinctly heard, the differentiation is easily
made.
In cases of combined obstruction and regurgitation, the two mur-
murs are present. The one, denoting obstruction, occurs while the
blood is being forced past the obstruction, that is, during the ventric-
ular systole, and is traceable along the arteries of the neck; the other,
denoting regurgitation, occurs while the blood is flowing back into
the ventricle, that is, following the second sound, and during diastole.
During the period of hypertrophy, a murmur is heard over nearly
all the arteries of the body. Thus, the stethoscope applied to the
femoral will reveal a bruit very like an aneurismal bruit, which is syn-
chronous with the aortic murmur.
DISEASES OF THE ORGANS OF CIRCULATION.
365
LESIONS OF THE MITRAL VALVE.
The mitral valve is particularly liable to disease, and to the physi-
cian its pathological conditions are most important.
While stenosis of this valve is relatively rare, insufficiency, or a
combination of both conditions, is one of the most common organic
troubles that come to the physician's notice. Unlike aortic lesions,
the mitral disease is more apt to make its appearance early in life,-
at any age when inflammatory rheumatism is prone to occur. The
endocarditis which so frequently accompanies that affection, seems
to have a special affinity for the mitral valve, while, on the other hand,
atheroma, so potent a factor in aortic disease, is not apt to attack the
mitral. The endocardial inflammation, by affecting the chordæ ten-
dineæ, and spreading over the edges of the segments, may ultimately
make of the original valve nothing more than a cone, protruding into
the ventricle, with a slit-like opening at the apex. This is the so-called
"button-hole " mitral.
The symptoms of both conditions are similar. The mechanical
obstruction offered is practically the same in its effects upon the cir-
culation and the remote organs. Of course, the first to suffer from
the engorgement are the lungs, and the symptoms mentioned under
that division of the general considerations appear.
The cough accompanying the congestion is of a dry, hacking char-
acter, and the feeling of "stuffiness" of the chest is not relieved by
expectoration.
There is abundant evidence that the nutrition of the lung is mate-
rially interfered with in many cases. It is not uncommon in elderly
persons to have an emphysematous condition develop; in young per-
sons the condition known as "brown induration " frequently appears.
The latter consists of an increase of the interlobular connective tissue,
an increase of the epithelium lining the alveoli, and the deposit of
dark-brown pigment in them. Pulmonary infarctions are also occa-
sionally observed.
The dyspnoea experienced is in proportion to the amount of con-
gestion, emphysema, or oedema. It is always present, and is one of
the most distressing symptoms. Cardiac asthma may develop under
these conditions.
Mitral Stenosis.
Etiology. This condition is comparatively rare. It is sometimes
observed, however, in young subjects as a sequence of acute rheuma-
tism and of endocarditis.
It is not well compensated for, because hypertrophy of the left ven-
tricle does not take place. Hypertrophy of the auricle occurs, but
even under the most favorable circumstances not much assistance can
be had from this source. The onward flow of the blood is interfered
366
A SYSTEM OF MEDICINE.
with, and it accumulates in the lungs and, later, in the right ventricle,
which becomes enlarged; still, it is inadequate to force the blood
beyond the obstruction, and general venous congestion soon occurs.
The prognosis is therefore worse than in mitral regurgitation. In
fact, this disease usually reaches a fatal termination in a compara-
tively short time.
Diagnosis. Inspection reveals nothing abnormal. Palpation re-
veals an epigastric impulse in advanced cases, but usually nothing
abnormal.
On percussion, the area of cardiac dulness is found increased in.
those cases in which the right ventricle is enlarged. The diagnosis
must be based upon the evidences furnished by auscultation. The
murmur heard in this condition is præsystolic. It is generally a soft,
puffing sound, which develops during the latter part of the diastole,
and continues up to the first sound of the heart-beat. It is heard
most distinctly at, or a little above, the left apex, and cannot be traced
to the left, or heard at the back, by which it can be distinguished from
the mitral regurgitant murmur. The sound itself is not constant.
Being rather faint, as a rule, it may be readily overlooked, if the heart's
action is rapid or tumultuous; but when the action is steady, it is
usually present. The heart's action is very likely to be irregular;
there will be two or three short, quick beats, and then one long, steady
beat. The murmur may not be distinguished during the weaker, but
may appear just before the stronger, beats.
The second sound of the heart-beat in both forms of mitral disease
is increased over the pulmonic semilunar valve. This is due to the
increased blood-pressure and recoil in the pulmonary artery.
The pulse may be small, irregular, and intermittent. These condi-
tions are variable. Sometimes the pulse will be regular, but will vary
in volume. Again, the irregularity and intermissions will be very
marked.
Mitral Insufficiency.
Etiology.-Mitral insufficiency is due to thickening and retraction
of the valve edges, after endocarditis. It may also arise from de-
formity due to vegetations, to atheromatous and calcareous degenera-
tions, or to dilatation of the left ventricle and the auriculo-ventricular
orifice in certain cases of disease of the aortic valves.
It is compensated for by dilatation and hypertrophy of the left
ventricle and auricle, and of the cavities of the right side of the heart.
It seems at first thought as though the left ventricle would not be
changed in structure by a lesion of the mitral valve, and this is true
in the case of obstruction, but in the case of insufficiency the ventricle
dilates on account of the augmented quantity of blood which is forced
into it under increased pressure from the auricle. It becomes hyper-
DISEASES OF THE ORGANS OF CIRCULATION.
367
trophic in order to be able to dispose of this amount of blood, which
it propels both forward into the aorta and backward into the auricle.
Prognosis. In this way the valvular disease is counterbalanced,
and the trouble held in abeyance for a considerable period.
The pulmonary engorgement is the most troublesome feature during
this otherwise satisfactory stage. It excites a cough and dyspnoea
when any slight exertion is made.
Finally, as in all valvular diseases, the time comes when the dilata-
tion predominates, when the heart is no longer able to pump the pro-
per quantity of blood into the arterial system, and when the patient
slowly sinks away.
Diagnosis. Inspection reveals some prominence of the præcordial
region, and displacement of the apex impulse to the left. Its beat is
sometimes felt to the left of the nipple line.
Percussion reveals an increase in the area of cardiac dulness which
is proportionate to the amount of the enlargement.
Auscultation is again indispensable to an accurate diagnosis. The
murmur which accompanies this lesion is systolic, and usually takes
the place of the first sound, and fills the interval between that and the
second sound. It occupies the same length of time which is occupied.
by the murmur resulting from aortic obstruction, from which it must
be differentiated. It is a firm, blowing murmur, heard most distinctly
over the apex of the heart. It is diffused towards the axilla, and in
most cases can be distinguished in the left interscapular space.
The murmur is lost as one listens towards the base of the heart,
which is a cardinal point of difference between it and aortic obstruc-
tion.
The pulmonic second sound is intensified by the increased pressure
under which the valves close.
DISEASES OF THE PULMONIC AND TRICUSPID VALVES.
Primary lesions of the valves of the right side of the heart are very
rare, especially in adults. As was stated in the beginning of this
chapter, these valves are apt to suffer from intra-uterine endocar-
ditis, but after birth they are remarkably free from the baleful influ-
ences which affect the valves of the left side. Secondary changes, how-
ever, are not uncommon, especially in the tricuspid valve. These
changes, as a rule, follow disease of the mitral valve, but they also are
sometimes associated with aortic disease.
As soon as they become diseased, a train of congestive troubles arise
in nearly every organ in the body. The liver, spleen, kidneys, brain,
intestines, and the extremities soon feel the effects of the partial stop-
page of the circulation, and, as compensation is entirely out of the
question, matters go from bad to worse, and the patient soon suc-
cumbs.
368
A SYSTEM OF MEDICINE.
Diseases of the Pulmonic Valves.-Cases of stenosis and in-
sufficiency of the pulmonic semilunar valves are on record, but are so
rare as to be among the curiosities of medical practice.
Insufficiency from overdistension of the pulmonary artery is the
most common pathological condition. Its existence is made known
by a systolic murmur heard at the left third costo-sternal articulation.
It is not traceable along the large vessels of the neck, and the pulse
has not the characteristics of aortic regurgitation, which also is accom-
panied by a systolic murmur.
But as both regurgitation and obstruction are so extremely rare, it
is seldom that the general practitioner is called upon to diagnosticate
them.
Diseases of the Tricuspid Valve.-Stenosis of this valve is an
unknown condition; insufficiency, on the other hand, is the most
common complication of mitral and aortic disease.
As soon as the condition is established, a long train of secondary con-
gestive troubles immediately appear. The skin becomes markedly cya-
notic, and presents an appearance characteristic of venous stagnation.
The superficial veins of the neck pulsate visibly from the force of the
ventricular contraction being transmitted backward. Dropsical effu-
sions soon appear and become enormous, and death ends the patient's
suffering.
The diagnosis is based upon the evidences furnished mainly by aus-
cultation. A systolic murmur, soft in character, is heard at the apex of
the heart, but most distinctly toward the sternum, and sometimes at
the ensiform cartilage. The area of dulness is enlarged, and the apex
is displaced. Sometimes a heaving impulse is seen to the right of the
sternum, which is due to the efforts of the dilated auricle. Venous
pulsations in the superficial veins of the neck are seen in this condi-
tion.
TREATMENT OF VALVULAR DISEASES OF THE HEART.
Formerly, when valvular lesions followed endocarditis, leaving the
heart-functions in a very disordered state, the condition was called
chronic endocarditis. We do not now recognize a chronic endocar-
ditis. Endocarditis exists so long as the temperature is above the
normal standard; after that, it is valvular disease simply.
The treatment may be divided practically into (1) Hygienic (2) Medi-
cinal. The Hygienic treatment consists in so ordering the life, habits,
diet, and exercise of the patient, that new attacks of endocarditis or val-
vulitis are prevented, that the process of compensation is not interfered
with or arrested, and that dilatation is not induced or increased.
To this end, rheumatic subjects should avoid exposure to cold and
dampness, should wear flannel of proper thickness through the year,
and not indulge in such diet or beverages as tend to induce the acid.
DISEASES OF THE ORGANS OF CIRCULATION.
369
diathesis.
The valves of the heart are left in such a state that their
condition is easily aggravated. We cannot modify the abnormal con-
ditions of the valves, except through the action of the heart. Thick-
ening vegetations, or insufficiency, cannot be directly removed by
medicines. We must prevent overstraining or irritation of the valves
by directing our patients to avoid all things which will unduly excite
or overtask the heart. Excessive muscular exercise, great mental ex-
citement, the intemperate use of alcoholic drinks, of coffee, tea, etc.,
promote the progress of valvular lesions, and should be avoided. Fast
walking, climbing, running, lifting should all be avoided.
After a time, however, if the patient has been careful in his habits,
and lived quietly, the valves become less irritable and liable to injury.
The walls of the heart become thickened, in order to overcome the
obstacles to the free circulation of the blood through the heart. Then
we have another trouble to avoid, namely: the tendency to weakness
and dilatation of the heart. It should be understood that we must not
seek to diminish hypertrophy, or the compensating thickening of the
muscular tissue of the heart, for upon this compensating hypertrophy
depends the safety of the patient. But we should strive to prevent
thinning or dilatation of the walls of the heart, for this condition leads.
to nearly all the evils which we dread during the progress of valvular
diseases. The hygienic directions given above will also prevent the
dreaded dilatation. But we should not err in the other extreme. We
should not compel the patient to live an inactive, sedentary life. Ex-
ercise, within certain limits, is highly important with a view to the
preservation of the power of the heart's action. Patients affected with
obstructive or regurgitant lesions will retain a compensatory vigor of
the heart, and the tendency to dilatation will be postponed better
by a judicious amount of exercise than by a life of complete re-
pose. Active occupations, free open-air exercise, as a calling or for
amusement, should not be neglected. Persons under the necessity
of working for a living will do better to continue such work, un-
less too laborious and overtaxing to the heart's energy, than to live a
life of inactivity. Inactivity of its muscular system tends to pro-
duce weakness of the heart and to form fatty degeneration, thus tend-
ing to the production of dilatation rather than the desired hyper-
trophy.
The diet also should not be too restricted. A healthy nutrition of
the heart, and thereby its muscular vigor, requires blood rich in nutri-
tive materials. A poor and insufficient diet tends to bring on the
very evils we wish to avoid. Animal food should be advised in judi-
cious quantities-not enough, however, to induce plethora. Liquids
weak in nutritive elements, even water in large quantities, should be
avoided. Fats-especially bacon, butter, and cream-may be used,
unless we fear fatty degeneration. Only nutritious and easily digested
VOL. I.—24
370
A SYSTEM OF MEDICINE.
vegetables should be eaten, for indigestion greatly irritates the heart.
Cheerfulness should be cultivated, and plenty of mental recreation.
indulged in.
Plethora should be avoided, and, when present, should be combated
by lessening the amount of animal food, coffee, or rich soups; and if
constipation be present, the moderate use of such waters as Carlsbad,
Congress, or Hunyadi should be advised. Anaemia is the most unfa-
vorable condition possible in valvular diseases. I have often been
called upon to treat these diseases in anæmic persons in whom the
anæmia was the sole cause of all the bad symptoms. With the
removal of the anæmia, by a highly nutritious diet, a life in the pure,
open air, and the judicious use of Ferrum, China, Aletris, and the
Hypophosphites, all the abnormal symptoms disappeared, even when
the valvular lesions remained in a modified form. It is well known
that anæmia and chlorosis will cause cardiac disorders, and even
valvular murmurs closely simulating organic disease.
Medicinal treatment of valvular disease, and its consequences, re-
quires judicious discrimination. I do not desire to detract from the
great merit and value of the modern medicinal treatment of valvular
lesions by our colleagues of the opposite school. It is as much in ad-
vance of their treatment of twenty-five years ago as the therapeutics
of Hahnemann were in advance of the practice of the dominant school
in his day. But even now they deal in generalities; they do not dis-
criminate closely between their cardiac remedies. When one potent
remedy fails, they select another, hap-hazard, because they will not
be guided by symptoms and special indications. The homeopathic
school labors under many disadvantages, but in another direction.
The number of our proven cardiac remedies is yet small, and those we
possess have not been thoroughly proven by means of the modern
aids to the diagnosis of cardiac action and cardiac disorders. There
are many potent cardiac remedies used successfully by the opposite
school, which are not used at all by our strict adherents who will be
guided by symptoms alone. I shall take the liberty to freely advise
the use of such remedies, giving as clear indications as possible, based
on the clinical experience of the great authorities in allopathy and
my own experience and observation. With our proven remedies we
are able to palliate many symptoms and distressing conditions, with-
out the use of narcotics, stimulants, or depletion, and we can use these
palliative remedies without interfering with the continued use of the
potent cardiac tonics which have been found so valuable by our
colleagues.
The general treatment of the consequences of valvular lesions is
based on the general indications (1) of favoring compensating hyper-
trophy, and (2) of preventing dilatation and cardiac weakness.
The first indication-namely: that of regulating compensating hy-
DISEASES OF THE ORGANS OF CIRCULATION.
371
pertrophy by (a) not allowing it to progress too rapidly, or (b) to
progress too slowly.
The medicines which appear to me to possess some power to retard
excessive hypertrophy, are: Veratrum viride, Erythroxyllum coca, Cactus,
Lycopus vir., Kali bromatum, Aurum, and Glonoine.
I
Ō
Veratrum vir., given in doses of th or th of a drop, regularly every three
or four hours, for days and weeks, will lower the abnormal force and frequency of the
heart's contractions. It matters not whether it acts on the cardiac ganglia or directly
on the muscular substance of the heart, this retarding action takes place quietly and
without producing any functional disturbance if the dose is kept within the proper limits.
As soon as the force of the heart becomes normal, the medicine should be suspended.
There are cases where Aconite can be substituted for Verat. v.
Coca has a similar action, but should not be used so continuously. Its sphere is
rather in those conditions of cardiac irritation brought on by excessive mental or
emotional excitement or physical exertion. In such cases a few drops of the tincture
or of the first decimal dilution calms the palpitation, when its use should cease. Coffea
(caffeine is one of the constituents of Coca) acts quite as favorably in some cases, in the
third (*) dilution.
Lycopus virginicus has a sedative effect on the cardiac ganglia or vaso-
motor centre, and a calming action on the heart. Its use can be continued for a long
time, if necessary. Its action on the circulation in Basedow's disease is proof of its
power in hyperstimulation of the heart. When the rapidly progressing hypertrophy
results in causing pulmonary hæmorrhage, this remedy is doubly indicated. The
dose should range from 10 drops of the 1 dilution to 10 drops of the mother tinc-
ture.
Cactus grandiflora or Cereus bonplandii are both indicated in too rapid
hypertrophy, where the force of the contractions is too forcible for the valvular lesion,
and when the blood-current is forced too strongly into the brain and lungs, inducing
cerebral and pulmonary congestion and hæmorrhage. Its well-known characteristic
symptoms are the guides to its use.
Kali bromatum is best indicated when the distant and reflex irritations (in-
testinal, ovarian, and cerebral) excite the heart, causing it to flush too intensely the
arterioles. A few doses of 5 to 10 grains, repeated every two or three hours, will have
a very beneficial effect.
Aurum mur. is recommended by Klapka for "venous stasis due to palpitation,"
or the "congestion of the brain" due to the same cause. When such conditions occur
in mitral disease (or functional disorder), Aurum is doubtless useful. It primarily ex-
cites and intensifies the force of the heart's contractions, and flushes with an active
arterial congestion all the organs and tissues of the body. Its recorded symptoms give
us a complete picture of this condition. The 3 dilution is the best preparation in such
cases.
Glonoine is to aortic valvular diseases what Aurum is to mitral lesions. It is
primarily homœopathic to active arterial congestion of the brain, with dyspnoea, great
pain in the chest and heart, almost equal to angina pectoris. I shall allude further on
to its use, as secondarily indicated (falsely called antipathic). Belladonna occupies a
position between Aurum and Glonoine.
It is evident that all the cardiac tonics are exquisitely homoeopathic to rapid hyper-
trophy, but I confess that I have never been able to observe such curative action as we
would naturally look for from the one chiefly indicated, namely: Digitalis.
Convallaria, Adonis, and Caffeine have not been sufficiently tested in
attenuated doses to enable us to judge whether, like Digitalis, they will fail us in ex-
cessive force of the heart's action.
Climate. In the condition of the heart above described, when the
blood current is too strong, also in true hypertrophy, it is often neces-
sary to advise the patient to change climate. I have often found
such patients to do well in a southern location, between latitude 25°
372
A SYSTEM OF MEDICINE.
and 35°, where the altitude is low and the atmospheric pressure is
high enough to counteract the increased blood pressure.
The second indication in the treatment of valvular disease of the
heart is to assist the heart in its attempts to accomplish hypertrophy
without dilatation, or complete compensation..
Fothergil clearly explains how unaided nature often brings this
about, namely: "Distension, which involves the elasticity of the mus-
cular fibre itself, that is, extending beyond normal distension till the
full length of the fibre is reached, and involving the secondary elonga-
tion of the fibres, or their elasticity, creates an impression in the car-
diac ganglia. This is quite in accordance with what we know; it is.
merely the normal stimulus in excess. From recent experiments we
learn that the heart possesses a sensory nerve, a fact which we would
conjecture from the pain accompanying heart affections, and especi-
ally acute ones, and this nerve has been found to be a vaso-inhibitory
nerve, i. e., it arrests vaso-motor nerve action, and dilates the peri-
pheral muscular extremity of the circulation, the arterioles. Thus is
not only the tension of the arterial system lessened, and with it the
opposition offered to the heart's more completely emptying itself at
each systole, but this affects the arterioles of the coronary circulation,
and thus a broader and more rapid stream of blood is furnished to the
heart itself, and so leads to hypertrophy."
But, unfortunately, nature alone rarely accomplishes complete com-
pensation, and when she fails, we get the two conditions described by
Traube: (a) "hypertrophy with dilatation, or incomplete compensa-
tion;" and (b) "simple dilatation or no compensation."
I have already given the treatment of incomplete hypertrophy. I
will now give the treatment of that most common sequence of valvular
lesions-simple dilatation or no compensation. The condition of the
muscular fibres of the heart's walls, in this condition, is one of weak-
ness and flaccidity. The heart itself is not nourished, because it is
actually starved. This may arise in some cases from an impoverished
condition of the blood, and our first duty is to see that it is enriched
by blood-making food, proper exercise in the open air where there is
an abundance of oxygen and no malaria. If this can be done, we
shall rarely be obliged to use Iron, Copper, Arsenic, and other hæmatic
medicines.
Then follows the use of certain medicinal agents known as heart-
tonics. These remedies act in the following manner: 1. They in-
crease ventricular contraction. 2. They arrest the dilating process,
and tend to institute a return to the normal size, and render more
normal the general circulation. We know that dilatation takes its
origin in incomplete systole, and a certain amount of blood remaining
in the ventricular chamber, when the blood rushes into the veins; for
the blood will pour into the ventricle as long as the pressure on the
DISEASES OF THE ORGANS OF CIRCULATION.
373
ventricular wall is less than on the venous walls, i. e., until the pres-
sure in veins and ventricles is equal, and no further. But when the
ventricle is imperfectly emptied, a compromise takes place in distension
of the ventricle and engorgement of the veins, in exact proportion to
the amount of blood already in the ventricular chambers. Thus, with
dilatation we get venous engorgement, one source of distress and mis-
chief, and imperfect filling of the arteries, another source of trouble;
for the elastic arteries transmit only what is poured into them. If
then a small bulk of blood is thrown into them at each ventricular
systole, the supply of arterial blood to all parts is diminished, includ-
ing the heart itself. Thus, dilatation has a tendency to perpetuate
itself, by this imperfect blood supply, in spite of the beautiful nerve
arrangement for increasing nutrition in distension. But when an
agent increasing ventricular contraction is administered, a larger bulk
of blood is thrown into the arteries and into the whole body, includ-
ing the heart itself. These agents are of benefit in another way; they
increase the periods of rest or sleep needed by the heart.
The medicines which are now well known to increase the power of
the heart's contractions, cause the contractions to be more ample and
slow, and regulate their rhythm, are the agents upon which we must.
rely to bring about perfect compensation, and thus make the circula-
tion of blood as normal as possible and prevent the evils of valvular
disease. These important agents are Digitalis, Convallaria, Adonis,Caf-
feine, Squilla, Erythrophleum, Euonymin, Belladonna, Glonoine, Strychnia,
Prunus virgin., and Aurum.
Digitalis has long been known as having a specific affinity for the heart. It was
long supposed to be a direct cardiac paralyzer, and was given in fevers to depress the
heart's force and action. But recent investigators have fixed definitely its place in
therapeutics, and have proved that it is a cardiac tonic, but with a double action, like
all other drugs.
Its primary action upon the healthy heart is to slightly quicken the number of beats,
but only for a short time, when its real tonic action begins. The contractions of the
ventricles become stronger, increase in force, and become slower, even to 30 or 40 per
minute. Up to this time, its action is physiological and harmless, but soon the con-
tractions become intermittent, and then irregular, but still very slow; the arteries are
filled to their fullest capacity, and the blood in the veins returns with force to the heart.
If the drug is continued, the contractions become less complete, because the cardiac
muscle is becoming tetanized, and soon the heart closes firmly with a permanent te
tanic spasm, which relaxes no more, and death ends the scene. But, if the drug action
stops just short of tetanic closure, the symptoms come on in reverse order. An utter
relaxation of the cardiac muscle follows, the ventricles become distended, beat irregu-
larly, intermittently, sometimes slow, then rapid; the arteries are not filled, and there
is venous stagnation. Its secondary effects are, therefore, similar to the secondary ef-
fects of valvular lesions, namely: distension, dilatation, and non-compensation. When
we use Digitalis in such lesions, we are using it homeopathically, not its primary homo-
opathicity, but its secondary. It cannot be called antipathic to such conditions. By
using it in physiological doses, we need not induce its ultimate toxic effects, but carry
its action up to the establishment of normal physiological action. I need not give
specific symptomatic indications. They are plainly enough given above. They are
the symptoms which show that the heart is failing in power, that over-distension is
causing dilatation, that the contractions lack in vigor, and are too rapid: that the ar-
teries are not well filled, and the veins are too full of sluggish blood. These are all
the indications we need, unless I call attention to the fact that this condition leads to
374
A SYSTEM OF MEDICINE.
200
arterial anæmia, and venous stagnation in the brain, lungs, liver, and kidneys, causing
cerebral paresis, dyspnoea, jaundice, and dropsy from deficient action of the kidneys.
All these remote conditions call for the use of Digitalis. The dose of Digitalis in such
a condition of the heart, and other organs, will range from 15 drops of the tincture to
15 drops of the 1 dilution, rarely less, and these doses must be repeated as often as
every 3 to 6 hours. A good trituration of the leaves (1 in 5 to 10-grain doses) is often
better than the tincture; and Digitalin, in doses of or-grain, is equally efficient.
Convallaria.-Next in order to Foxglove, and perhaps superior in many re-
spects, is the Lily of the Valley. In experiments on warm- and cold-blooded animals
it has been proved that Convallaria primarily causes a slowing of the heart's contractions,
with decided increase of the blood pressure; at the same time, it augments the ampli-
tude of the contractions. This means that each contraction throws a stronger and larger
current of blood into the arteries, and that every organ in the body is supplied with a
larger quantity of arterial blood. In a further stage of its primary effects these power-
ful contractions are accelerated, with a greater increase of blood-pressure. Soon this
stage ends in sudden diminution of blood-pressure and arrest of the heart's action.
After death the ventricles are found firmly contracted, pale, and empty. The provings
on man show that, during its primary effects, there are palpitations, intermittent and
irregular pulse, congestions of the head and chest, and other similar phenomena. The
secondary effects, due to hyperstimulation of the heart, are failure of the muscular
power of the heart, irregular, feeble contractions, low blood-pressure in the arteries,
and venous stagnation. Clinically, it has been found useful in all conditions of the
heart, due to valvular stenosis or insufficiency, when the ventricles are suffering from
over-distension, and dilatation begins; when there is incompleteness or absence of
compensation, and the system suffers from deficient arterial blood-supply, and when
there is venous stagnation. It is claimed by those who have used Convallaria largely,
that it seems to act best in disease of the right side of the heart. This is my own
experience during several years of observation. Digitalis, on the contrary, is
more successful in derangements of the left heart. This gives Convallaria greater
power over pulmonary congestions, dyspnoea, and orthopnoea. In fact, its most bril-
liant results have been in those terrible dyspnoeas which occur in valvular diseases of
the right heart. Dr. Troetzki calls particular attention to its power in removing the
torturing attacks of dyspnoea during compensation, also when the patient cannot take
the least bodily exercise without producing palpitation. Associated with these symp-
toms there is a mental irritability, almost amounting to insanity. All this group of
mental and physical symptoms are promptly removed or greatly palliated, in a few
days, by Convallaria. My own experience is that, in women with functional or struct-
ural diseases of the heart, with great nervous irritability, horrible dreams, hysterical
manifestations, Convallaria gives more relief than any other drug. Its power in re-
moving dropsy due to cardiac disease is sometimes marvellous, but always in propor-
tion to its restorative power over the failing heart. But all observers, myself included,
have found that, if there was albuminuria present, its action as a diuretic was much
less. If the heart disease is secondary to kidney trouble, it may act favorably in im-
proving the condition of the heart, may restore its power and regularity of action, and
increase the arterial blood-pressure in the kidneys, but, if these organs are damaged
seriously, neither Convallaria nor any other remedy can cause an increased flow of
urine. Convallaria has many advantages over Digitalis. (1) It rarely causes gastric
or intestinal irritability; it rarely, if ever, causes vertigo and confusion of the head,
and never irritates the bladder, in the doses required to bring about its curative ac-
tion. (2) It has not the sudden toxic action supposed to be possessed by Digitalis.
I do not believe that Digitalis, Convallaria, or any heart-tonic has any "cumulative" ac-
tion so-called. When massive doses of any of them are given, there comes a time when
the contractions become tetanic. This endangers or destroys life. But such an occurrence
should never take place when the patient is under the care of a watchful physician, or
in a patient of ordinary intelligence. When the pulse and the heart's beats become
too hard, and tightness of the chest occurs, the medicine should be suspended for a time.
Convallaria seems to possess the power of continuing its action for a week, or more,
after its use is suspended, so there need be no fear of losing time by stopping its ad-
ministration.
There are some important and practical facts connected with the comparative value
of the preparations of this drug. It is said that all parts of the plant, flowers, leaves and
root, contain the active principles of the plant. But I have not found the preparations
of the root and leaves, to be of as much value as those from the flowers. I use and
advise only a concentrated tincture or fluid extract of the fresh flowers. Of this I
give from 1 to 15 drops every 3 to 6 hours, according to the gravity of the case. The
DISEASES OF THE ORGANS OF CIRCULATION.
375
dose should be largest when the failure of the heart's power is greatest. Only in chil-
dren and infants have I found the 1 dilution of sufficient power. Remember that
heart-failure, over-distension, etc., are all secondary, and that the secondary effects of
all cardiac tonics simulate secondary valvular troubles. Convallaria is only primarily
homœopathic to abnormal excitation of the heart with abnormally high blood-pressure,
In such cases
as in plethora, hypertrophy with enlargement, functional neuroses, etc.
it ought to prove curative in the attenuations.
Adonis vernalis.-This remedy, like Convallaria, comes to us from Russia,
and like many of our best remedies was first used by the common people-as a remedy
in dropsy and heart-diseases. Experiments were first made by Dr. Botkin. The ex-
periments made on both cold-blooded and warm-blooded animals with different prepa-
rations of Adonis (infusion, and both aqueous and alcoholic extracts) showed that its
action is to stimulate both the inhibitory apparatus and motor ganglia of the heart,
to increase the contractility of the cardiac muscles, and to cause the contraction of
small arteries in different parts of the organism, without affecting the vaso-motor
centre. Under its influence in cases of dropsy, the cardiac contractions increase in
force, the pulse becomes less frequent, more regular, and fuller, the urinary secretion
increases from 200 to 2000 or 3000 cubic centimetres, and albumen and casts disap-
pear from the urine. In cases where the dropsy was due to a disturbance in the
compensation and activity of the heart, this remedy acted very satisfactorily. The
heart-beat increased in force, and the size of the heart rapidly diminished; the heart-
sounds and murmurs, especially the presystolic and systolic murmurs in stenosis, were
more marked and distinct. The heart-rhythm was more regular and somewhat slower,
therefore the pulse was slower, and in most cases fuller and slower. The urine in-
creased from 300 to 3000 cubic centimetres, a tenfold increase of the watery element.
All deposits disappeared, specific gravity diminished, and the urine had a very pale
color. There was an absolute increase of the chlorides and urates, the body weight
diminished, and the oedema decreased rapidly: the dimensions of the liver increased;
cyanosis and dyspnoea disappeared, and respiration became full and regular.
In the largest number of cases great relief was experienced at the end of the first
day, complaints were less frequent, and in the course of a few days disappeared entirely.
These clinical results were obtained in hospital practice, where the cases were
closely and carefully watched.
Adonis is indicated in cases of (a) Endocarditis, with valvulitis, when the heart-mus-
cles are endeavoring to overcome the valvular obstruction, and need the aid of specific
remedies to increase the tonicity of those tissues: or (b) when there is impending or
actual dilatation of the heart, from a giving way of the muscular fibres. This condi-
tion is marked by diminished force of the heart's action, with lowered blood pressure
everywhere, especially in the kidney, decreasing their functional activity.
It has been found equally potent in secondary heart disease, following Bright's dis-
ease, when we find a diminished action of the heart, pulse irregular or intermitting,
passive venous stasis, dropsy, etc. A typical case from these hospital records is as
follows: "A common laborer with chronic valvular disease, with dilatation. After
the use of Adonis the heart diminished in size, the congestion of the lungs, well
marked, almost disappeared, the oedema of the legs and ascites disappeared entirely,
palpitation of the heart and dyspnoea diminished so much that the patient was dis-
charged from the hospital, and returned to work."
The dose of Adonis, when given in infusion (zi. of the herb to iv. of water) is a
tablespoonful every 2 hours in severe cases; in chronic, every 4 hours. The dose of
the tincture is 5 to 10 drops, of the fluid extract 1 to 5 drops.
Adonidin, the active principle, is an amorphous powder of a very bitter taste; dose,
For a grain. By the above it is seen that Adonis is quite similar, if not identical,
to
in its action on the heart, to Digitalis and Convallaria. The symptomatic differences
have not yet been brought out by any physiological provings; but we can resort to it when,
as is often the case, the two medicines above named fail to act favorably, or cease to
give the patient relief. It is said to be more liable (than Digitalis) to cause gastro-
intestinal irritation, nausea, vomiting and diarrhea-in large doses.
Caffeine, the active principle of Coffee, Tea, Guarana, Mattee, Kola, and other
plants used as a beverage, was not known as a cardiac tonic until 1863, when Kaes-
schlakoff, of St. Petersburg, published his treatise on Caffeine in cardiac affections.
Homeopathists know from our provings that Coffee is a cardiac stimulant, and it has
been long prescribed by us in palpitations, due to mental excitement. In Allen's En-
cyclopædia of Materia Medica are published some sphygmographic tracings, but they
do not give an adequate idea of its power over the contractions of the heart.
376
A SYSTEM OF MEDICINE.
The earlier investigators of Caffeine, who observed its effects in toxic doses, which
are similar to the toxic effects of Digitalis, wrongly decided that it was a cardiac de-
pressant. Recent investigations, both in health and disease, have established the fact
that Caffeine in moderate doses, a few grains daily, diminishes the pulsations of the
heart, augments the vascular tension, augments the amplitude of the contractions,
removes venous stasis, acts on the kidneys (even when they are badly damaged), and
greatly increases the quantity of urine. At first, small doses were given, a fraction
of a grain, carefully, and doubtful of the safety of larger doses. But lately, Drs. Dujar-
din-Beaumetz, Lupene, and Herchard have boldly given massive doses (from 5 to 30
grains daily), and claimed to have gained marvellous curative effects from such doses.
These doses may shock the sensibilities of those of our school who are wedded to
the use of infinitesimals. To such I would say that the axiom with which Hahne-
mann opens his Organon should silence all such objections. The cure of our patients
is our sole duty, and the size of the dose should be selected solely for its beneficial ef-
fect in disease. In no malady is this truth so important as in valvular diseases of the
heart. While we may not cure our patients, we can render their sad lives comfortable
if we lay aside narrow notions and use remedies in such doses as will give the best
results.
Dr. Dujardin-Beaumetz says in his Clinical Lectures-"You will see veritable
resurrections effected by this marvellous therapeutic agent, and this even in aged per-
sons; therefore you ought to have these facts always in mind, and remember that in
the asystolic period-period of cardio-plegia, as Gubler called it-when you have ex-
hausted the remedial powers of all the cardiac tonics, you may still obtain signal effects
with Caffeine."
I have verified the above statements in many desperate cases, when I have been
called in consultation, in patients who seemed already at the entrance of the "dark
valley," their hearts almost in a condition of ventricular paralysis, and who were
being rapidly "drowned" by the rising tide of apparently irremediable dropsy. Un-
der the use of a few grains a day (I have rarely prescribed more than eight), I have
seen these patients get rid of their dropsical accumulations, their terrible dyspnoea,
and with fairly beating heart, begin anew, and with hope, the journey of life. Even
if we do not restore the damaged heart, it is surely something to calm and strengthen
its pulsations, and relieve for a time the sufferings of our patients.
The methods of administration are various. We can use the decimal triturations,
and get prompter effects than with the crude drug, for with a more minute division of
its particles we get an augmentation of medicinal power, e. g., ten grains of the 1* will
give us better effects than one grain untriturated. I have given it in sugar-coated gran-
ules of 1 to 1 gr. each, which some patients prefer.
Τσ
If we feel obliged to give larger quantities, as in treating cardio-plegia, it is best, ac-
cording to Dujardin-Beaumetz, to give it largely diluted, for in its crude form such
doses cause gastric distress. He advises the following formula:
B Caffeine,
Benzoate of soda,
Water,
•
7.00 (or grs. 105)
7.00 (or grs. 105)
250.00 (viii)
Each teaspoonful of the above contains 50 centigrams, or about 7 grains, which
may be given two or three times a day. Instead of water, a mixture of syrup and aqua
gaultheria or menth. pip. may be substituted to disguise the taste. It is only in des-
perate cases, however, that such large doses will be required.
Sometimes you will have patients, in advanced stages of heart disease with dropsy,
who cannot bear any medicine on the stomach. You are supposed to have tried all
our best remedies for gastric irritation and the cardiac failure, but with no avail. You
feel that you cannot let your patient die without giving a trial to every possible means
of relief. In such cases you can resort to hypodermic injections of Caffeine. The fol-
lowing preparation of Tanret's is the best:
R Salicylate of soda,
Caffeine,
Distilled water,
•
Dissolve with the help of heat. Inject 10 drops every six hours.
gr. xlvii.
zi.
Ziss
Remember, I am referring to extreme cases. In the majority of cases of cardiac non-
compensation without dangerous symptoms, a few grains of the first three decimal tri-
turations will be found amply sufficient to restore the heart to fair working order for
a long period, aided by the use of such other remedies as are indicated by the condition
of the patient.
DISEASES OF THE ORGANS OF CIRCULATION.
377
Squilla has not been used by the homoeopathic school in heart affections. At the
time the original proving of Squills was made, no method of testing its effects upon
the heart was in use. But if a careful study of these provings be made, it will be seen
how closely its chest and respiratory symptoms compare with the bronchial and plen-
ritic troubles which are so often present in mitral lesions. Owing to the imperfect
supply of blood to the lungs in the mitral disease, the lungs, and especially the bron-
chial mucous membrane, become congested; this causes a profuse flow of mucus (bron-
chorrhoea) or acute bronchitis; also edema and venous stasis of the lungs; and even
pleuritic effusion. The cough, in such cases, closely resembles the cough of Squilla,
namely: loose, rattling, constantly harassing, day and night; sometimes loose, then
dry, spasmodic, disturbing sleep; loose in the morning, dry in evening. The ex-
pectoration is either glairy or bloody, and is very difficult to raise, although a large
quantity seems to be in the chest.
The allopathic abuse of this drug is fearful. They give it to "loosen the cough."
They do not know that the bronchorrhoea, which they cause, is due to congestion of the
lungs and bronchial mucous membrane, depending on cardiac weakness, and irregular
action; and that many of the fatal cases of so-called bronchitis and pneumonia in
children, are made so by the toxic action of Squill. If the patients did not vomit up
most of the drug, the mortality would be greater. The pathogenetic action of Squills
is not unlike Convallaria (all the liliacea, in large doses, are more or less cardiac
poisons). The primary effects of large doses of Squill is to cause increased force and
more rapid contractions of the ventricles; the pulse is small and hard, wiry, then be-
comes irregular and very rapid, and finally ceases from tonic closure of the ventricles.
During this time the pulmonary circulation is rendered imperfect, and there is present
passive congestion. Hence the cough, mucous rales, bloody sputa, dyspnoea, pleuritic
pains, profuse urine, etc. It is my conviction that nearly all the symptoms of the chest
and urinary organs caused by Squill are produced by the action of this drug on the
heart, and, except in a small class of influenzas, it is only indicated in chest affections
when cardiac disorder is present. Many of the cases diagnosticated as bronchitis, pneu-
monia and pleurisy, in children, are probably due to acute endocarditis, pericarditis,
or chronic valvular diseases, which we now know are very common in early life. In
acute cases, presenting the characteristic symptoms of Squill, it should be given in
minute doses (3¹ dil.), or the malady will be dangerously aggravated.
Per contra, in cases of cough, dyspnoea, bronchorrhoea and pleuritic affections of a
neglected or chronic nature, when the symptoms often assume the character of the
secondary symptoms of Squilla, namely: constant hawking, loose or dry cough, great
oppression of breathing, movement, or lying down, aggravate; the face is pale and cold,
hands and feet cold and blue, heart's action feeble, irregular, palpitating, but always
deficient in force, urine scanty, red, painful and often bloody, this remedy will be found
promptly curative in larger, but not pathogenetic, doses. I have found the 1' dilution,
in doses of five drops every hour, or the 11 trit. in grain-doses, act with the happiest
curative effect. In dropsy from valvular disease it should not be used empirically, but
always selected by the ensemble of its symptoms. The domestic use of Allium cepa,
in cases such as I have described above, often results in rapid cures, for the onion is
but a mild Squill.
Erythrophleum is a plant found on the coast of Guinea. It is a unique
poison to the heart, whose toxic effects combine those of Digitalis and Cocculus. Its
primary effects are very similar to Digitalis, but just as the ultimate primary effects
begin to appear, the Picrotoxin effects set in. The pathogenetic and clinical effects
have not yet been sufficiently studied to enable us to use it with certainty. Professor
See and others are now using it in heart affections in the Parisian hospitals. They
find it very useful in cardiac asthma.
Euonymin.-The active principle of Euonymus has been found by experiments
on animals to be a cardiac tonic, increasing the power and amplitude of the heart's
contractions. I have verified this fact clinically in many cases, and its curative sphere
of action is clearly defined in my mind. We know that among the sequelæ of valvular
heart affections passive congestion of the liver and jaundice often hold a promi-
nent place. We also know that idiopathic hepatic congestion and jaundice often cause
a slow, weak action of the heart. In either of these conditions Digitalis has been used
successfully when Podophyllin and Mercury were powerless. Euonymin is in these
cases as near a general specific as we shall find, and when I meet with them I invari-
ably and unhesitatingly prescribe Enonymin in the 1 or 2 trituration, a few grains
every few hours. Under its use the heart soon beats stronger and quicker, and more
regular, the urine becomes lighter, and the bile in it gradually disappears; the stools
soon assume a darker hue, and the jaundiced skin clears up. There are several kinds
378
A SYSTEM OF MEDICINE.
of Euonymin, the green, light-brown and dark-brown Experiments have shown that
the dark-brown possesses greater medicinal power, while the green is almost inert.
This accords with my personal observations.
Glonoine.—The homoeopathic school are well acquainted with the use of this
drug in congestions of the brain, where it is prescribed for its peculiar primary effects.
I have alluded in a previous paragraph to its use in those active congestions which
occur during the period when the hypertrophy is too rapid in its progress.
There is no record, however, of its clinical use in our school for cerebral anæmia, a
condition to which it is supposed to be "antipathic," but which I consider secondarily
homoeopathic. I shall treat of its use in angina pectoris, where I compared it with its
swifter analogue, Amyl nitrite.
Dr. Dujardin-Beaumetz, in a recent lecture on new cardiac medicaments, mentions
it favorably in aortic disorders, to which, he says, it is particularly applicable. He pre-
scribes it for the cerebral anæmia which is such a distressing accompaniment of aortic
lesions. This anæmia comes, he affirms, "from the trouble inflicted on the arterial cir-
culation, and which manifests itself by pallor of the countenance, attacks of vertigo,
lypothymia, and even syncope; we are called upon to mitigate the distress which
attends these sorts of affections, whether this be in the form of symptomatic neuritis of
the cardio-pulmonary plexus, a result of propagation of the peri-aortic inflammation
to the numerous plexuses which surround that vessel, and thence to the peripheral
nerves, or whether we are concerned with that veritable angina pectoris of which Hu-
chord has so well explained the mechanism in his recent work, showing us that these hor-
ribly painful paroxysms of thoracic angor result from ischemia of the cardiac muscle."
In aortic diseases, not only the vessels of the brain and lungs, but the coronary arte-
ries are subject to paroxysms of extreme tension, due to vaso-motor spasm. Herard
compares this with the condition of the arterioles in senile gangrene.
But
Now, to this condition Aconite, Secale, and Ustilago are primarily homoeopathic,
and we have clinical proof that Secale has been found curative in such cases.
these remedies, with the exception of Aconite, are not sufficiently rapid in their action
to relieve the sudden and intense paroxysms. Amyl nitrite has been used successfully
as a palliative, but it is open to the objection that its action is too ephemeral. Glonoine,
however, acts in a few minutes, and the duration of its action lasts several hours. Grant-
ing that it is "antipathic," why should we not use it as well as Alcohol or Ammonia?
In ischemia of the brain and cardiac muscle, when the distress is like that of angina
pectoris, the face pale and cold, with cold sweat, syncope, and almost impending
death, a single drop of the first centesimal dilution will, in two minutes, flush the
face, warm the skin, relieve the syncope and cardiac distress, and give us time to get
a lasting specific action from Cactus or Convallaria. Glonoine arouses and energizes
the beating of the heart, relaxes the coronary and cerebral arteries, and does it much
more safely and surely than alcohol or any general stimulus.
Nux vomica and Ignatia, by virtue of the Strychnia which they contain,
have a specific action on the muscular fibres of the heart. They act on the heart mus-
cle, through the nervous supply proceeding from the cerebro-spinal centres. We have
no more important and certain remedy than Strychnia, in all conditions of the heart
when there is paresis or paralysis. In certain cases of dilatation with thinning of the
walls and exhaustion from intracardiac pressure, the heart is often in a condition
aptly termed cardio-plegia. In such cases neither Digitalis, Convallaria, Adonis, nor
other specific cardiac tonics, seem to be sufficient to restore the tone of the heart's
muscular fibres. Here Strychnia, by acting through different channels, will often
arrest the impending paralysis, and increase rapidly the motor vitality of the heart.
It does not seem to control irregular and intermittent action as well as Digitalis and
its analogues, but it has more power over the contractions of each muscular fibre.
Very often it becomes necessary to alternate Strychnia with Digitalis, or to give them
in combination; and I do not believe there is anything illogical or unscientific in such
combination of differently acting drugs. My experience with such a combination has
been so satisfactory and brilliant that I could not be induced to reject it. I have for
many years used a compressed tablet, made by Boericke & Tafel, each one containing
Digitalis folia, or solid extract, gr. th, and Strychnia, gr. b. Of these, I prescribe
one every 6 or 8 hours. Under their use the heart's action becomes regular and
forcible, and unless the damage is irremediable, soon resumes its normal action and
functions. In anæmic cases the Citrate of Iron and Strychnia, in does of 5 grains of
the 1, is an admirable remedy.
Prunus virginian. has long had the reputation of acting on the heart
similarly to Digitalis. Although not as potent a remedy, it certainly will often regu-
late a weak heart. The best preparation is the "Detannated fluid extract," which
DISEASES OF THE ORGANS OF CIRCULATION.
379
may be given in 15 to 30 drop doses. Several years ago, acting on the suggestion of
Fothergil, of giving Digitalis with Iron in cardiac disorders with anæmia, and not
finding any preparation which suited me, I directed the well-known chemists of Chicago,
Chapman, Green & Co., to make a compound of Digitalis and Iron, in detannated fluid
extract of Wild Cherry. Each teaspoonful contains gtt. 5 of tinc. Digitalis, Ferr.
phos., gr. i, and Wild Cherry ext., gtt. 10. I have received great satisfaction from the
use of this compound, and do not hesitate to recommend it to the profession. Dose: a
teaspoonful three or four times a day.
I will now briefly allude to the more common sequelæ or conse-
quences of valvular diseases.
Dropsy is the most important. This is due to deficient arterial
tension in the renal arteries, and this condition is caused by deficient
power in the heart. No so-called renal remedies, i. e., drugs which act
directly on the kidneys in a manner to induce profuse flow of urine,
are of real value in cardiac dropsy. They can only act as mere palli-
atives, and often do more injury than benefit.
Only those remedies which act by increasing the regularity, force, and
amplitude of the heart's contractions, are of any permanent value. These
I have enumerated above. There are others, not mentioned, which have
proved of great value, but full and recent investigations into their physi-
ological effects show that they do not act directly and specifically on
the kidneys, as was once supposed, but are really cardiac energizers.
Apocynum cann., Asclepias syriaca, Juniper, Collinsonia, Stigmata
maidis, Eupatorium purp., Iberis, and Benzoate of Ammonia, all act
on the kidneys through the heart. These are so well known to our
school, except two, that they do not require separate mention. Of the
two, Iberis and Stigmata maidis need some comments.
Iberis amara was used long ago in dropsy with enlarged heart. I made some
experiments on animals and provings in men, which showed that it acts like Digi-
talis, and clinical experience has shown it to be useful in some cases. It is not as
certain in its action, however, as others of this class, and in the doses required to pro-
duce its specific effects on heart and kidneys, is not as well borne as others.
Stigmata maidis was first introduced and used as a sedative remedy in irri-
table conditions of the whole urinary tract. It was considered as an analogue of
Triticum repens, but was soon found to have a wider sphere of action. Not only is
it one of the most potent remedies in irritable conditions of the ureters, bladder, and
urethra, but it is a powerful diuretic in renal disorders, unconnected with cardiac de-
rangements. Still later, a recent French investigator, Dr. H. Dupont, has studied its
action on the heart, and thus sums up the results:
(1.) It renders the heart's action slower and stronger.
(2.) It regulates the rhythm.
(3.) The diuretic action is almost always manifested the very first, and goes on in-
creasing up to the thirteenth or fourteenth day.
(4.) In cardiac affections, with oedema of the lower limbs and general dropsy, this
beneficial action is the most prompt and most evident.
(5.) While the dropsy diminishes, and often disappears, the arterial tension in-
creases, and the venous tension is reduced concurrently; the general condition becomes
decidedly improved, and, in particular, the author mentions a subjective feeling of
calmness and bien être, except there is pronounced dyspnea, which it does not remove.
(Convallaria has the same effect, and also removes the dyspnea.) In hypertrophy
and stenosis, Stigmata maidis always produces good results. The author thinks it acts
more powerfully than Digitalis, and with about the same energy as Convallaria, but
that it is to be preferred because it never produces unpleasant effects. When I read
Dr. Dupont's report I could hardly believe that the corn-silk, so apparently inert, taste-
less, and simple, could be capable of such profound influence, but I have verified the
380
A SYSTEM OF MEDICINE.
Dr. H.
Dr. H. uses an
truth of his assertions in several cases.
the formula. I have found the fluid extract, in doses of
times a day, to be the effectual dose.
((
extract"; he does not give
20 to 40 drops, three or four
Copaiva has been found to diminish the dropsy in cases which resisted all other
renal and cardiac remedies. I remember one case, apparently hopeless, where the
resin of Copaiva, in doses of 1 grain (in pill), every two hours, run off an enormous
anasarca in a few days. This same patient had a return of the dropsy in a few
months, and Copaiva had no effect, but Caffeine, 3 grains every four hours, rallied the
almost paralyzed heart, and caused a most enormous flow of urine, and gave a new
lease of life.
Arsenicum, so generally recommended in all our routine text-books as a
remedy for all kinds of drosy, never was of any use in my practice. It certainly has
no place in cardiac dropsy any more than China or Quinia
There are cases of dropsy from cardiac disease wherein all reme-
dies will seem to be inert, and we are left apparently powerless.
There seems to be an unknown factor in the body, which prevents the
action of all medicines. What this factor is we should try to ascer-
tain. Sometimes it appears to be the liver. Once in a case of this kind
I happened on a remark of Stokes, that "after a mercurial, diuretics.
seem to act promptly." Acting on this hint, I gave the patient a few
doses of Merc. dulc. 1, and in less than a day the diuretic (Asclepias
syr.) acted with great activity, In other cases I have had similar
effects from Podophyllin 1' or Iridin 1', and some German authors
report similar results from the tincture of Carduus marianus. Another
fact is that, when diuretics fail to act, a brisk hydragogue-purgative,
like Jalap or Elaterium, will be followed by a condition which allows
the diuretic to act.
This leads to the question whether we are justified in using hydra-
gogues in cardiac dropsy. The testimony of the allopathic school is
decidedly favorable, and many, eminent in our school, approve of
them. My own experience is decidedly in their favor.
Χ
We should never allow sectarian bias to influence us in the treat-
ment of the sick. The remedy which gives relief should be used, no
matter what it is. I have treated many cases, in which neither cardiac
nor renal remedies gave relief. The dropsy was enormous, and was
rapidly drowning the great vital organs. Here the most magical relief
was given by a single grain of Elaterin 1 or 2*, repeated every three
or four hours. The amount of water expelled from the bowels under
its use was enormous, sometimes amounting to two gallons per day.
And most surprising was the physical and mental relief, and the actual
increase of vigor and strength in the patient, after each evacuation
from the bowels. In fact, when Elaterin is imperatively called for, I
have never seen any prostration induced. Bitartrate of potash often
has a very happy effect, in such cases, but its action is not as certain,
yet I have seen enormous dropsies run off by the administration of
this medicine, in doses of 1 drachm, repeated every four or six hours.
The dose is best given in a glass of lemonade.
In bad cases, in which a cure is impossible, all the above means will
DISEASES OF THE ORGANS OF CIRCULATION.
381
fail. We must then resort to scarification or puncturing the lower ex-
tremities, or sloughing will occur. Punctures with a hare-lip pin or
hypodermic needle are preferable. To prevent erysipelas, wrap the
limb, after puncturing, with flannels wrung out of warm water. Dysp-
naa is one of the most obstinate as well as most distressing symp-
toms of weak heart with dilatation or non-compensation. When it
is due to venous congestion, the cardiac tonics, Digitalis, Convallaria,
and Adonis will relieve. In pulmonary edema, the sitting posture
relieves, or Chloral hydrate in doses of 5 to 10 grains every few hours.
Aromatic ammonia should be given for rapid stimulation. If it is
paroxysmal, Cannabis indica, Grindelia, Arseniate of antimony, Lobelia
inflata, or Quebracho, will give relief. Of this last-named medicine
but little was known at the time I mentioned it briefly in my New
Remedies. But it has been the subject of an exhaustive study and
clinical observation by a Spanish physician (Moriasi y Lorrion), of
the Princess Hospital staff, Madrid. He claims for it, in dyspnoea, a
superiority over all other remedies. It causes a diminution of the
number of cardiac pulsations and of respiratory movements, and it
augments the force of the heart's contractions. It, therefore, acts on
the heart similarly to Digitalis. Dr. M. calls it, "the Digitalis of the
lungs," for it strengthens and regulates the respiratory movements.
He says its continued use is not dangerous, nor does it cause unpleas-
ant symptoms, except in massive doses, when headache, vertigo, and
dimness of vision occur. He gives 2 to 4 grammes of the tincture
(30 to 60 gtt.) at a dose, in simple syrup, every two hours. I prefer
smaller doses, repeated every half hour or hour (10 to 15 drops in syrup).
Sometimes all these remedies will fail in dyspnoea, and we are obliged
to resort to some preparation of Opium to give temporary relief.
Hypodermic injections of Morphia are well borne by many patients,
who get from them a relief from sufferings worse than death. Begin
with grain of Morphia mur. If this seems to cause "sinking of
the heart," as they term it, add to each dose grain of Atropia. In
several cases when Morphia was not well borne, relief was obtained
from Codea phosphate, in doses of to grain. A single injection at
night often turns the night of agony into one of comparative comfort.
After seeing instances of such relief, no humane physician will feel.
like rejecting its use.
10
Cough may be exceedingly troublesome, and may be constant or
paroxysmal. For the former, Lachesis, Naja, or Apis is often sufficient.
The latter form requires Belladonna, Hyoscyamus, or Lactucarium.
Rare and obstinate cases require Morphia, grain, or Codea grain.
Sleeplessness, or sleep interrupted by horrible dreams, waking in
fright or great distress, is usually controlled by Hyoscyamus, Cimi-
cifuga, Monobromide of camphor (gr. i), Grindelia, Cannabis indica,
Coffea, or Bromide of sodium (20 gr.). Some patients can only sleep
382
A SYSTEM OF MEDICINE.
in a sitting posture, with the head bent forward on the back of a chair,
with the head supported by a sling, as recommended by Walshe.
HEART-CLOTS.
Synonyms.-Thrombosis of the heart, Fibrinous coagula within
the heart; French, Thrombose cardiaque; German, Gerinnungen im
Herzen.
Definition.-By heart-clot is meant the formation of a blood-clot
within the heart; a mass of fibrin or coagulated blood deposited in
the cavities of the heart during life.
Looking at this condition from a pathological, not from a physio-
logical, standpoint, we must distinguish heart-clots formed during life,
which lead to various symptoms of disease, from the natural post-
mortem heart-clots which, except in rare cases, present themselves in
the normal heart when an examination is made. These latter, or
passive, coagula are formed sometimes just before death, bringing on
the death struggle; or after death, when the functions of life cease to
be performed. They are found chiefly in the auricles, may occupy
all the passages of the heart, and sometimes extend into the large
pulmonary artery and other vessels. They are of a black or reddish
appearance; or appear as masses of hard fibrin, whitish, translucent,
containing serum, or there may be the two kinds found together.
But the distinguishing characteristic lies in the fact that they are in-
dependent of the surrounding structures; there may be a slight adhe-
sion, resulting naturally from the moisture of the parts and from the
jelly-like nature of the fluids, but they are not truly adherent; they
have not been formed by a process of growth, and are easily separated
from the endocardium.
The real pathological blood-clots, which alone are discussed under
thrombosis of the heart, are formed some time before death, are not the
result of natural coagulation, and are to be found away from the track
of the blood currents.
Etiology. The cause of thrombosis of the heart is due to a con-
dition of the blood which may favor coagulation if suitable circum-
stances (like the stasis in the right ventricle and the rough surface of
the cavities of the heart) are present, or which may retard its own
action; or it may be due to local causes, defect or disease in the heart
itself, by which the formation of coagula may be facilitated. The
vegetations in endocarditis may give rise to a thrombus; and a deposit
of fibrin, once started, makes easy the further development of the
condition. If the heart has some organic disease which admits of
but a slow and feeble action, a thrombus is easily formed, which may
itself be directly the cause of death, though not the primary trouble.
Pathological Anatomy. These clots are to be found especially
in the recesses of the heart's cavities, where the blood current is not
DISEASES OF THE ORGANS OF CIRCULATION.
38
regular, in the appendices auriculorum between the columnæ car-
neæ; the cavities on the right side seem the commoner seat of thrombi,
though the left auricle and ventricle often are affected. There are
two varieties of this ante-mortem clot; in the first, which resemble
those post-mortem, the cause is traced to a hæmorrhage, when the
system is weakened, as in childbirth, or to the shock of a surgical
operation; in the second variety the clot bears the appearance of age;
if it is cut through, it appears laminated "like an onion;" the face
surface is smooth and rounded, while the deep surface adheres more
or less tenaciously to the endocardium; they project from their lodg-
ing places like knobs or balls; in the interior it is less solid than on
the outside, and contains often a fluid, puriform substance of bad
odor. The color of the interior is irregular, sometimes white, yellow-
ish, sometimes spotted with red or black spots.
Symptomatology and Diagnosis.-The coagulum once formed,
it continues to grow, gradually involving the structures to which it is
attached, preventing the free action of the valves or of the chordæ
tendineæ; they may gradually obstruct the passage of the blood by
filling up the cavities or an orifice; sometimes, however, these thrombi
may be partly reabsorbed, when the system asserts itself, or fragments.
may break off and be carried into the arterial system-as emboli.
(See section on Emboli.)
The objective symptoms of heart-clot are indefinite, and resemble
rather the symptoms of the last stages of chronic heart disease. When
the coagulum is the result of hæmorrhage (i. e., formed suddenly) the
most striking symptom is exertion in breathing, as if the air admitted
to the lungs were not sufficient; this is not the case, however, for the
clot forms in the right ventricle, prevents the passage of the blood,
and the lungs lack their usual quantity of blood to aerate. The pulse
is reduced, but rapid; there is faintness and irregular beating of the
heart; respiration is full; we have a sonorous sound in breathing; the
patient is agitated, and craves for air; the veins are swollen, and cya-
nosis is marked. When the thrombosis is gradual, the symptoms.
appear slower, and when the left chamber is affected they are less
pronounced; we find distress, pain in præcordia, restlessness, irregu-
larity in heart movement, pulmonary congestion, etc., but the few well-
marked characteristics are so nearly related to those of chronic heart
trouble, that the physician can prescribe only in a general way.
Prognosis. The prognosis is most unfavorable, death being merely
a question of time; partial absorption may assist in reducing the
danger, but it is of rare occurrence; all we may hope to do is to secure
a postponement of the end. The case may last from a few days to six
weeks.
* This liquid may have been absorbed from outside the mass, or it may be the re-
sult of disintegration from within.
384
A SYSTEM OF MEDICINE.
Treatment. It is evident that there can be no treatment for a clot
once formed in the heart. But we can adopt a treatment which may
prevent the formation of clots, and possibly assist in breaking down
a clot while in process of forming.
It is said that the introduction of alkaline salts into the blood tends
to prevent its coagulation. Of these, the Ammonia-salts are most po-
tent. These salts are also of themselves stimulants, and aid in keep-
ing up the tone of the muscular tissues.
In the treatment of all diseases of the heart we should be on the
alert to detect any symptoms of failure of its muscular power, for in
this failure is the greatest danger of the formation of blood-clots. It
is equally so in hæmorrhages from any organ, for with the loss of
blood comes a tendency to failure of the power of the heart.
The remedies, then, to prevent heart-clot are those which prevent
heart-failure. They are Digitalis, Convallaria, Adonis, Strychnia, Atropia,
Caffeine, Nux vomica, Ignatia, China, etc.
At the risk of inviting criticism, I must insist that we cannot use
successfully medicines primarily homœopathic to heart-failure (like
Aconite, Veratrum, etc.). The difficulty to overcome is one that de-
mands powerful cardiac tonics, i. e., tonics by their first action.
In pure cardiac failure, symptoms are of little value in the selection
of the drug. I would recommend from my own experience and ob-
servation, as well as from the testimony of the best authorities, that a
combination or alternation of certain cardiac tonics gives us the best
prospect of success.
I know of no more powerful and efficient means to attain this end,
than the alternation of Digitalis (5 gtt.), and Strychnia (zo gr.),
Convallaria (5 gtt.), and Ignatia (1 gt.), or Adonis (5 gtt.) and Nux
vomica (1 gt.). In some conditions I have substituted, temporarily,
Atropia 20 grain or Caffeine 1 gr., for the Strychnia. These should
be continued-2 or 3 hours apart, or oftener-until the heart's action
becomes regular and strong, or as nearly normal as the condition of
the heart will permit. I advise this practice not on theory, but from
actual clinical experience.
A favorite prescription in my practice, and one that will sustain the
heart's action as long as there is any vitality in it, or arouse it from
profound paresis, is as follows:
& Spirits Ammon. Aromatic.,
Tinc. Digitalis, .
Hall's Solution Strychnia (1 gr. to 3i),
Syrup,
NONO
Zi.
3ss.
Zii.
Ziiss.
Mix. A teaspoonful every hour or two (until the heart's action is restored).
This is heroic treatment, but such treatment is required when car-
diac paralysis is imminent.
I always give the Aromatic Spirits of Ammonia when I fear the
DISEASES OF THE ORGANS OF CIRCULATION.
385
formation of heart-clots. One teaspoonful in nine of water, with a
spoonful of glycerin or syrup, is not disagreeable; and I know of
nothing so grateful to the sinking patient, who feels its stimulating
influence with each dose. A teaspoonful can be given as often as
every five or ten minutes in bad cases, or as often as the case seems
to require. It antidotes none of the above named remedies, and can
be given with all.
Together with these medicines, the patient must be placed in a con-
dition of absolute immobility; any movement of the body may thwart
our efforts.
The hands and feet and chest should be kept warm by mustard ap-
plications, or hot water simply. (Rubber bags filled with hot water
are excellent.)
Food should be given at brief intervals, not solid, but in the form
of hot milk, coffee, beef-tea, or peptonized beef extract.
All these means should be persisted in until the circulation is es-
tablished and auscultation shows that the heart beats with sufficient
force to convey the blood current through the valves with normal force.
ANEURISM OF THE HEART.
Definition.-Cardiac aneurism is properly a pouch, like a circum-
scribed dilatation, occurring in one or more of the anatomical divisions.
of the heart. (Flint.)
This term "aneurism of the heart" was, at first, improperly applied
to any or to all dilatations of the cavities, "whatever its cause or its
character," but examining the definition of general aneurism (q. v.)
as applied to the heart, we see that dilatation is too general, for the
circumscribed cavity must be distinct from the auricles or ventricles,
though, of course, directly connected with either of them, and the
contents of this cavity must be something more than the normal blood
fluid in transitu.
Description.-The cardiac aneurism occurs most frequently in the
left ventricle; a few cases, only, have been found in the other chambers.
The size may vary greatly; sometimes it is not larger than a small nut,
sometimes larger than the heart itself. The contents are generally the
same as those of other (arterial) aneurisms, condensed fibrin, various
coagula. Often there is a calcareous deposit. This sac looks like a
rounded and projecting tumor, or, in one case, "it assumed the appear-
ance of a sac winding round the base of the aorta " (Quain). Or the
aneurism is seen only when the heart is exposed from the inside. The
cavity may be merely a depression, shallow or deep, containing de-
posits or fibrin; or the opening may be very small, hardly large enough
to admit a finger, widening according to the size of the tumor itself.
This neck may be hard or smooth, regular or irregular. The walls
may be continuations of the centric walls of the heart, beginning inside.
VOL. I.-25
386
A SYSTEM OF MEDICINE.
with the endocardium, and ending bounded by the pericardium, or
the muscular substance may have entirely disappeared.
Etiology. The most prolific cause of cardiac aneurism is change
in the substance of the heart itself, whereby resistance to the blood-
pressure is diminished, and the walls are allowed to give way. This
gradually bulges outwards till a size as above described is formed. This
weakness of the heart's substance may be due to acute or chronic in-
flammation, to fatty degeneration, or to growths of various kinds. It
is easily seen how any inflammation should destroy the strength of
the walls, and especially when the endocardium is ruptured, how an
aneurismal sac should result. Or, in an inflammation, pus may be
formed, which, when discharged, leaves a depression easily converted
into a proper aneurism. When any growth turns soft, an aneurism
may be formed in the above manner; or, where fatty degeneration is
in process, the weakened tissues may give way to the blood-pressure,
and the cavity thus formed be, in time, converted into a true aneu-
rism. Syphilitic myocarditis may also give rise to an aneurism.
However, the subject practically belongs to the discussion of morbid
anatomy.
Little can be said concerning the diagnosis before death, or in regard
to any positive symptoms which could lead to a careful selection of
remedies homœopathically. The patients are usually of advanced
age, the occurrence of an aneurism in young persons being the ex-
ception.
Aneurism primarily caused by an inflammation is called acute,
though all pursue a more or less chronic course. Death may result
from obstruction of the heart's action, from burrowing into the walls
of the heart, or into another cavity, or from sudden rupture, by which
death is brought about by mechanical means.
Symptomatology.-According to all authorities, the symptoms.
are not to be distinguished from those of myocarditis, for in any case
a grave disturbance of the heart is all that can be noticed, and no
physical signs are distinguishable.
C. DISEASES OF THE PERICARDIUM.
PERICARDITIS.
BY PEMBERTON DUDLEY, M.D.
Synonyms.-Inflammation of the pericardium; French, Perí-
cardite; German, Herzbeutelentzuendung.
General Character and Varieties.-Inflammation of the peri-
cardium may be diffuse or circumscribed, acute or chronic. It may
affect at the outset either the visceral or the parietal portion of the
membrane, and from a circumscribed beginning may extend until it in-
DISEASES OF THE ORGANS OF CIRCULATION.
387
volves the entire serous surface. In a majority of the cases in which
the
a post-mortem examination reveals the true condition of the parts,
inflammatory action is found to have been coextensive with the mem-
brane, but it is not at all unlikely that there are very many cases in
which the lesion is less extensive, the symptoms less severe, and re-
covery takes place without the patient, or even the physician, having
been aware of the nature of the malady. Indeed, it is not doubted
that a circumscribed pericarditis may, and often does, run its course
without the production of pain, or of any other marked symptom. It
is unsafe, therefore, to undertake even an approximate estimate of the
relative proportion of circumscribed and diffuse cases, since even the
existence of so many cases is undiscovered either before the death of
the patient or subsequently.
When the inflammatory action is circumscribed, it is more likely to be
located on the surface of the auricles and about the base of the heart,
or around the origin of the great vessels than elsewhere, although any
other part of the pericardial surface may be affected in the first in-
stance. One of the reasons why many cases of circumscribed peri-
carditis are free from pain as a symptom, is due to the fact that the
seat of disease is at a part where the friction of the opposing surfaces.
is almost nil, the base of the organ furnishing perhaps the most marked
illustration of this statement.
The disease may run a brief course and terminate favorably, con-
stituting the acute type of the malady, or, on the other hand, it may
continue indefinitely, constituting what some have termed chronic
pericarditis. It seems, however, that between these two forms there
are few points of essential difference, save in their severity and in their
duration. There is, says Bauer, "no sharp boundary line between the
two categories."
The tendency, almost invariably manifest, to the formation of exu-
dations at some stage of the disorder, gives rise to still another classi-
fication dependent upon the character of the exudation, which may
be fibrinous, sero-fibrinous, purulent, or hæmorrhagic. This classification.
seems to be a perfectly legitimate one, since the character of the ef-
fused fluid does not always depend upon varying degrees in the in-
tensity of the morbid action, but quite frequently seems to be deter-
mined either by some constitutional predisposition or else by the
quality of the cause which superinduces the attack. Especially is
this true of the purulent and hæmorrhagic forms of exudation.
Etiology. As regards the causes which may induce pericarditis,
it cannot be questioned that the pericardium is liable to the same for-
tuitous circumstances as other tissues, and, like them, is subject to
inflammations of both traumatic and idiopathic origin. As a conse-
quence of its deep situation, however, and the protection afforded by
the bony and muscular thoracic parietes, as well as because of the
:
388
A SYSTEM OF MEDICINE.
special care of the individual over the vital thoracic organs, we find
that traumatic pericarditis is of quite rare occurrence.
Traumatic pericarditis, when it does occur, is quite commonly
the result of penetrating wounds of the chest, or the lodgment of for-
eign bodies in the pericardial or adjacent tissues. A violent blow
upon the chest walls, with extreme concussion, or a crushing weight,
resulting in more or less extensive laceration, are also regarded as
among the mechanical causes of pericarditis either by direct injury to
the part itself or by extension of inflammatory action from some in-
jured neighboring tissue.
Idiopathic pericarditis constitutes the type in which, with but
rare exceptions, the disease presents itself to the general practitioner.
Of this form there are two ætiological varieties, the primary and the
secondary. Primary idiopathic pericarditis is that form in which the
attack occurs as a primary disorder, and not as a mere localized mani-
festation of a more general malady, nor as a result of the suppression
of morbid action in some other portion of the body. This variety of
the disease is quite rare, and some writers appear to be in doubt
whether the few cases met with may not after all be secondary, i. e.,
due to some undiscovered disorder. As indicative of its comparative
rarity, Duchek reports but one case in a total of eighty-nine, and
Bamberger found but five primary cases in an aggregate of sixty-three
(Ziemssen). Yet it would be absurd to suppose that the pericardial
membrane may not be liable, like the peritoneum and the pleura, to
congestion and inflammation under the influence of a chill, the sudden
suppression of a secretion, or, in fact, from any other of the causes
usually assigned as the precursors of serous inflammations elsewhere.
The causes capable of producing the secondary variety of idiopathic
inflammation of the pericardium are quite numerous, and seem, in
some instances, to be quite destitute of essential similarity. This is,
perhaps, equivalent to saying that the modus operandi of the produc-
tion of these secondary forms is not at all understood by the patholo-
gist, and such a statement would embrace an unfortunately large
measure of truth. The more common causes are acute articular rheu-
matism, fatty degeneration of the kidneys, and other forms of renal
disease, scarlatina, diphtheria, variola, and measles, typhus, and even
typhoid fevers, erysipelas, pyæmia, also cancer, tuberculosis, scurvy,
etc. It is also a frequent accompaniment of severe pleuritis, pneu-
monia, hepatitis, and inflammation of other neighboring organs. Be-
sides these, there appear to be others of a more obscure character.
By far the most common of these causes is acute articular rheuma-
tism; indeed, so liable is pericarditis to supervene in the course of
this complaint that the discreet physician is ever on the alert to de-
tect the signs of its inception, not only in severe cases of articular in-
flammation, but also in its lighter forms, though it is true that the
DISEASES OF THE ORGANS OF CIRCULATION.
389
cardiac inflammation seems more frequently to occur when the rheu-
matism is severe than when it is less so. It does not seem that the
disease of any particular joint, or class of joints, is more prone to ex-
cite the cardiac inflammation than others. Pericardial inflammation
does not occur in chronic articular rheumatism, nor in rheumatic in-
flammation of a single joint, nor in muscular rheumatism, nor in
gout."*
When pericarditis supervenes in the course of an acute articular in-
flammation, its beginning is most usually observed during the second
week; less frequently between the fourth and seventh days; but it
may occur either later or earlier. The invasion of the pericardium
may occur coincidently with that of the articulations, or it may
begin in the cardiac tunic first, and appear in the articulations after-
wards. Indeed, it is held that rheumatic inflammation has been
known to begin and end in the pericardium without attacking the
joints at all.
So far as clinical and post-mortem observations have extended, the pro-
portion of cases resulting from chronic disease of the kidneys does not
exceed one in fifteen or twenty, fatty degenerations appearing to be the
most prominent of the renal conditions likely to give rise to pericardial
trouble. Pleuritis, pneumonia, and peri-hepatitis are far more prolific
sources of the malady than the one just mentioned, while numerous
cases of inflammation of the heart's muscle, or even of its lining, may
eventuate in an attack upon the external coat of the organ. Can-
cerous cachexia and tuberculosis are less frequently a cause of the dis-
ease we are considering, than might be supposed.
Reports are on record of pericarditis occurring endemically, but
these cases seem to have been due to an unusual prevalence of those
maladies which so frequently give rise to inflammatory processes in
the pericardium. In one such, reported by Hubert, it was evidently
due to the prevalence of pleuro-pneumonia among the soldiers of a
garrison. The exudations in these cases were frequently found to be
of a purulent character.
The disease is more prevalent in middle life than either in child-
hood or in advanced age, a fact obvious enough when the character of
its exciting causes is considered. When the disease occurs in child-
hood or early youth, it is quite often the outcome of either pleuritis,
pneumonia, scarlatina, or measles. The writer remembers to have
seen one case following a severe attack of whooping-cough, in which a
post-mortem, made by Dr. C. S. Middleton, of Philadelphia, revealed
a number of circumscribed pulmonic abscesses, the pericardial inflam-
mation having been followed by a rapid and profuse sero-fibrinous
exudation.
* Bauer. See Ziemssen, vol. vi., p. 557.
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A SYSTEM OF MEDICINE.
The relative mortality in pericarditis is a matter exceedingly diffi-
cult to establish. According to four different reporters, quoted by
Bauer (op. cit.), the percentage of fatalities varied from 12.5 to 16.2 per
cent. This was under allopathic treatment. What the mortality rate
is under the homoeopathic method, we have no means of knowing.
Pathology and Morbid Anatomy.-It has been already men-
tioned that inflammation may attack either layer of the pericardial
membrane; generally, however, it seems to prefer the visceral portion
and the region of the origin of the great vessels; even when both layers
have been involved throughout their entire extent, it is not uncommon
to find that the greatest intensity of the morbid process has seemed to
centre about the base of the heart and on the visceral layer.
cess.
The morbid change begins as a simple hyperæmia, the surface be-
coming congested and exhibiting the fine network of vessels so often
seen in other situations in the early stages of the inflammatory pro-
Doubtless here, as elsewhere, the disease may be checked, and
the parts again return to their normal condition; but otherwise, its
intensity augments rapidly, a dark-red color overspreads the surface,
the membrane swells and thickens, and exudation speedily super-
venes, particularly on the visceral layer, and preferring the base of the
organ as its seat, but soon covering the entire space involved in the
inflammation. This exudation, adhering to the serous surface, may
form, at first, only a thin, delicate layer, like the "bloom" upon the
surface of a purple grape, and through which the deep-red color of the
serous membrane is still distinctly visible. More frequently this
fibrinous layer acquires considerable thickness, and presents an un-
even, rugous surface on which ridges, papillæ, and other prominences
array themselves in every possible shape and order. This appearance.
has been likened to the rugous surface of a piece of " tripe," and, more
accurately by Laennec, to two flat surfaces spread with butter, pressed
together, and then pulled apart. The exudation is both adhesive and
elastic, as a consequence of which, numerous small round strings or
broad flat bands are formed, stretching across the space between.
the visceral and parietal layers, sometimes dividing this space into
closed compartments, large and small, in which portions of the
thinner, serous exudation which follows may be imprisoned. The
color of this adhesive exudation is usually either yellowish or reddish-
white.
The exudation is composed largely of a fibrino-plastic matter,
derived from the pericardial capillaries. As a consequence of its
organizable nature and of the inflamed condition of its serous, under-
lying surface, it speedily manifests a tendency to take on a permanent
existence. Newly-formed, minute blood vessels, communicating with
the serous plexus, make their appearance in the plastic layer, which
becomes more firm, and steadily takes on the characters of a more
DISEASES OF THE ORGANS OF CIRCULATION.
391
complete organization. This process involves not only the general
layer, producing a pseudo-membrane, but extends throughout the
length of the trabeculæ or cords stretching from layer to layer. In
case the two pericardial surfaces are in contact, organized adhesions.
are thus formed between them, and cases are not unfrequently met
with in which the pericardial sac has been thus nearly or entirely ob-
literated by the agglutination of its opposite walls. Much more fre-
quently, however, the adhesions are limited in space, or the incoming
watery, serous exudation, which so generally follows the fibrinous,
may so distend the sac as to prevent adhesions from forming at all,
and this is doubtless aided by the constant movements of the heart
within its pericardial chamber. At times, the thinner fluid seems to
dilute or otherwise change the character of the fibrinous mass, as to
render it unorganizable, in which case it is liable to undergo destruc-
tive metamorphosis, and take on a purulent character. Moreover, the
original exudation is found to contain numerous migratory, nucleated
cells from the serous vascular plexus, these being most numerous in
the deeper portions of the exuded layer. The abundant out-pour of
cell-elements frequently so changes the physical characters of the ex-
halation that rapid disintegration follows, and the case becomes one
of purulent pericarditis. It is not believed that the effused substance.
is ever originally purulent in character, like that so often seen in the
peritoneal sac, but that the pus formation is always secondary. It is
quite certain, however, that various constitutional causes of pericar-
ditis, such as pyæmia, typhus, active tuberculosis, etc., can exert a
marked influence in determining the abundant cell-formation which
leads to this secondary result.
Following out from this point the general subject of purulent pericar-
ditis, there are one or two other explanations to be offered respecting
the existence of pus in the pericardial cavity. The purulent destruc-
tion of the pseudo-membrane is sometimes accompanied, according to
Rindfleisch and other observers, with a destructive action upon the
serous surfaces also. This destructive process has been known to in-
volve material loss of sub-serous tissue, and even to perforate the wall
of the sac. Wyss mentions a case in which the disintegration made
its way also through the rib and established a fistulous outlet through
the chest walls. On the other hand, pus may find its way into the
pericardium through the parietal membrane from a pulmonary ab-
scess or other purulent accumulation pressing against its external
surface.
Not unfrequently it is observed that the exudation exhibits a slight
admixture of blood, due simply to an unusually high grade of inflam-
matory action. Alcoholic intoxication is said to cause this condition,
which is doubtless purely mechanical in its origin. But there are
other cases of hæmorrhagic pericarditis in which the extravasation of
392
A SYSTEM OF MEDICINE.
blood has a far graver significance, being the result of serious consti-
tutional predisposition, particularly the scorbutic diathesis, or of
severe acute diseases, as scarlatina, variola, etc.
It occasionally happens that the fibrinous formation is not followed
by any considerable amount of serous effusion. Such cases have
been, rather erroneously, denominated "dry" pericarditis. Generally,
however, the serous out-pour follows closely, rapidly, and abundantly,
so much so indeed as to subject the parietal layer to considerable dis-
tension, and the heart itself to a dangerous degree of compression.
This serum consists of the watery elements of the blood, holding in
solution certain of its mineral salts, with usually a small portion of
its coloring principle. Its color, however, may vary from a pale
amber to a bright yellow, from an exceedingly delicate greenish hue
to a dark brown, or from a pale pink to a deep hæmorrhagic red.
Most frequently we find it to have either a decided yellowish or
greenish color, although a brown tint is by no means uncommon.
The various degrees of red or pink are due, as might be supposed, to
extravasation from the delicate newly-formed vessels of the fibrinous
layer already described. The effusion, if free from hæmorrhagic ad-
mixture, is generally transparent. When, however, as is sometimes.
the case, it exhibits more or less opacity, the fact is due to the pres-
ence of large numbers of cells that have found their way into the fluid,
either directly from the vessels or from the plastic exudation, or which
have been produced in the course of a pus-formation going on in the
fibrinous mass. Not seldom it contains floating, detached flakes of
plastic substance. The distension of the sac obliterates the friction of
the heart in its impulse, and aids in preventing adhesions between the
layers of pericardium or rupturing those already formed. Its pres-
sure has been known to produce a thinning of the parietal layer,
though generally such an amount of pressure would result fatally long
before this more gradual change could be effected in the fibrinous
tissues of the sac wall, and the usual fact is that the inflammation
affects both the serous and fibrous laminæ, and produces an actual
thickening.
In making post-mortem examinations of those who have died of
pericarditis with extensive serous effusion, we shall find that as the
body lies in the supine position the heart sinks, from its greater
specific gravity, and the fluid accumulates above it. There may be
instances in which adhesions prevent this relative position from
occurring, and these connecting bands may be found to change the
position of the apex beat.
We come now to the consideration of the steps and processes subse-
quent to completion of the effusion, and which constitute the terminal
changes of the inflammatory action, presupposing that life has con-
tinued throughout its course. And first, as to the more serous or
DISEASES OF THE ORGANS OF CIRCULATION.
393
watery effusion; its absorption through the general serous surface,
and doubtless also by the vessels new-formed in the pseudo-mem-
brane, may take place quite promptly and rapidly. Sometimes, how-
ever, the inflammation falls to a lower grade of severity, and persists
in its continuance, forming a chronic pericarditis, in which case the
effusion may disappear in part, but not often entirely. These cases.
are complicated by a liability to frequent exacerbations with re-effu-
sions of serum, additional plastic exudations, and an increased danger
of either a hæmorrhagic or a purulent involvement, with, sooner or
later, a fatal ending.
The absorption of the fibrinous exudation is not so simple a process,
but in many cases it seems to disappear almost entirely. At any rate,
it is not uncommon to meet with cases in which nearly all traces of
its presence subsequently disappear. The substance in these cases
undergoes a fatty degeneration, and in this condition is gradually
absorbed. In connection with the fibrinous formation, and especially
with the plastic adhesions, there is often a new development of con-
nective tissue, this evolution changing the character of the serous mem-
brane itself, so that where the two layers are brought into a close and
permanent adhesion their serous character is lost, and their separa-
tion, even by the scalpel, becomes next to impossible. This develop-
ment of connective tissue, it must be understood, does not involve a
transition in the fibrinous exudation, but is dependent upon the cells
therein contained, and probably also upon the fully formed tissues of
the pericardium itself. The fibrinous mass is afterwards changed by
fatty metamorphosis, and absorbed. The new connective tissue thus
formed is sometimes the subject of still further unfavorable changes,
particularly calcification, the dense fibrous layer becoming in exceed-
ingly rare cases a coat or shell of calcareous infiltration, inclosing the
heart in a resisting wall.
Hæmorrhagic exudations are also frequently absorbed, particularly
when the hemorrhage has been but slight, and mingled with a large
amount of serous or fibrinous exudation. The grave character of
these cases consists but rarely in the extent of the hæmorrhage, but
usually in the nature of the pre-existing condition which has deter-
mined the character of the whole morbid process. Purulent accumu-
lations are of still more grave import, yet it still ends in absorption
and recovery. In such cases it would seem the watery portions are
directly absorbed, and the thickened purulent mass takes on a fatty
degeneration, and is thus taken up without seriously endangering the
patient. In some instances the purulent masses become encysted,
and remain indefinitely without involving danger to life.
It could scarcely be possible that, in the majority of severe peri-
cardial inflammations and effusions, the subjacent muscular struc-
tures should escape involvement. For not only do we find that the
394
A SYSTEM OF MEDICINE.
fibrous pericardial layer often takes part in the morbid process, especi-
ally when the disease exhibits a chronic tendency, but the subsequent
connective tissue proliferation involving this layer may extend in-
wardly as well as outwardly; and Virchow has demonstrated this con-
dition in the muscular layers near the pericardial surface. It is be-
lieved that the pressure of the effused fluid may so far interfere with
the nutritive circulation in the cardiac tissues as to superinduce fatty
degeneration, which, perhaps usually involving only the outer portions
of the structure, may in some cases pervade the entire thickness of the
muscle. According to Wagner, about fifty per cent. of his post-mortem
examinations revealed this myocarditic lesion in relation with peri-
cardial inflammation and effusion. These changes in the muscular
structures, and its consequent weakening, often lead to dilatation and
subsequent hypertrophy, and thus may be the beginning of one of the
long series of grave functional disorders likely to impair the patient's
health irretrievably.
Pericarditis has also been assigned as a cause of endocarditis, and
Desclaux has demonstrated by experiment that the latter can be in-
duced by the former. It is quite doubtful if in the numerous cases in
which the two diseases run a coincident course, the external inflam-
mation can be safely considered the cause of the internal, since it
happens that the same primary causes which generally originate the
one, can also give rise directly to the other. Particularly is this true
of acute rheumatism and of pyæmia.
Symptomatology.-One of the most marked characteristics of
pericarditis consists in the uncertainty of its subjective symptoms in
the earlier stages. It is not at all uncommon for the disease to make
very considerable advances, or even, in some cases, to run its complete
course without having been suspected to exist either by the patient or
his physician. The symptoms which in some cases are violent and
agonizing, in others may be almost unnoticed or altogether lacking.
It has been only through many disastrous experiences that the medi-
cal profession have learned the need of extreme watchfulness in all
forms of disease liable to pericarditic complication, and never to de-
pend upon the patient's sensations alone, as warnings against its in-
sidious invasion.
In cases of primary pericarditis the early symptoms may be not at
all pronounced; and when some other primary disease develops a
secondary pericardial inflammation, even an extensive one, there may
be no chill ushering in the morbid complication, no increase of pulse, no
added rise of temperature, no spontaneous pain, no sensitiveness, per-
haps, even to local pressure. These negative indications, rather let us
say: these utter absences of all indications, in the presence of a possible,
yet unseen, peril, have made the wise physician solicitous and vigilant.
The first indication that presents itself in some few cases, is only a
DISEASES OF THE ORGANS OF CIRCULATION.
395
sense of oppressive languor, incapacitating the subject for energetic
activity; and even this may not appear until hours or days have
elapsed. In other instances, however, the signs of intense and grave
morbid action are sufficiently numerous, intense and significant.
Among these we may here catalogue the following, viz.: pain, sensi-
tiveness to pressure, quickened pulse, increased temperature, anxiety,
pallor, hiccough, vomiting, insomnia, perhaps delirium, and these to
be followed later, when effusion shall have supervened, by dyspnœa,
orthopnoea, dangerous syncope, etc. Yet this whole series could scarcely
be accepted as evidence of pericarditis, unless corroborated by the fric-
tion murmur elicited by physical examination. These symptoms we
propose to consider briefly in successive order.
Pain. Although pain may be lacking in the beginning of the com-
plaint, yet there are cases in which it constitutes a predominant symp-
tom. Generally, however, it is not violent. In primary pericarditis
it is felt in the lower portion of the præcordial region and extending
from the sternum to the apex, or nearly so. This pain may be of a
dull character, but not unfrequently it is lancinating and severe, while
from its central point the pain radiates downward and outward to the
epigastric and left hypochondriac region, upward to the left axilla, and
even down the arm. This pain is often spontaneous, though coughing
and deep inspiration, as well as pressure over the præcordial space, ag-
gravate it. From the first two of these aggravating causes, but chiefly
from the peculiar character of the pain itself and the direction of some
of its radiations, it has been thought by some to be pleuritic rather
than pericardial. Others claim to have observed it in the absence of
pleuritis.
A far more frequent symptom is a dull painful pressure in the præ-
cordial region; and this accords with the view of numerous histolo-
gists who have been led to doubt if the serous pericardium is acutely
sensitive like the pleura and peritoneum. Rochefontaine and Bour-
ceret, however, in a paper read before the Paris Academy of Sciences,
October, 1877, have claimed to demonstrate experimentally that the
pericardium in disease is quite acutely sensitive, both in its external
surface and in its thickness (Paul). The dull pressure, just mentioned
as existing in the præcordial region, is also felt in the epigastrium, where
it is increased by pressure made upon the external surface by deep in-
spiration and by bodily movements. Under the influence of general
muscular movement, the aggravation may be sufficient to enforce ab-
solute quiet on the patient's part, especially if, as sometimes happens,
dyspnoea is also induced. These pains in the præcordium and epigas-
trium are also sometimes radiating.
There are two other localities in which pain, particularly on pressure,
may be sought. One of these is above the edge of the clavicle, between
the two origins of the sterno-cleido-mastoid muscle, and the other in
396
A SYSTEM OF MEDICINE.
the angle formed by the lower border of the costal cartilages and the
xiphoid process, on either side, but chiefly on the left. The first-
mentioned of these is over the trunk of the phrenic nerve, and the
other at the level of their termination. The pains, when they exist,
are held to be due to irritation of these nerves.
Fever. The indications of the presence of fever are to be received
cautiously. The increase of temperature is usually not very great, and
if the primary causative disease has been attended with febrile dis-
turbance, it may be that no noticeable increase of temperature will
occur; indeed, the experience of numerous observers furnishes united
testimony to the occurrence of a decided fall of temperature in febrile
diseases, when pericarditis has supervened. In acute cases, occurring
in advanced life, Charcot reports this phenomenon: typhoid fever has,
in two cases cited by Brouardel, shown a remarkable depression upon.
the development of a pericardial inflammation, and Lorain noticed the
same change of temperature when a secondary pericarditis developed.
in the course of acute rheumatism. Paul mentions these cases, and
attaches value to their significance, as possibly adapted to aid the
physician in learning of the approach of a disease which otherwise.
might not be so soon detected. The same author makes note of another
peculiarity of temperature, namely: that sometimes while the general
surface is "very hot, the limbs are notably cold."
It sometimes happens that where no marked fever has previously
existed, as, for instance, where a pericardial inflammation develops in
the course of a chronic disease, there may be a marked rigor, followed
by high temperature. The same is true, as already intimated, of the
primary type of pericarditis. When the disease runs a slow course,
the temperature is usually not much above the normal. In the case
of young children, as when pericarditis follows advanced convalescence
from scarlet fever, there is usually some return of febrile heat, and in
all cases this is true in the later stages of pericarditis whenever it
happens that the exudation takes on a purulent character.
The acceleration of the pulse is sometimes a very noteworthy indi-
cation. It may reach, in adults, a rate of one hundred and twenty
per minute, and in young children a still greater rapidity. The in-
creased rate, however, is not usually of long duration, and by the time
the effusion process is well under way, it may have returned almost to
its original condition. Later on in the disease there may be a retarda-
tion of the pulse, due to cardiac exhaustion from the pressure of the
effused fluid, or from the muscular lesions in connection with the
too frequent extension of the inflammation into the subpericardial
tissues.
The acceleration of the pulse cannot be regarded in precisely the
same light as a similar condition occurring in other diseases. It is to
be remembered that the morbid process going on upon its serous
DISEASES OF THE ORGANS OF CIRCULATION.
397
surface must, for the time, greatly increase the excitability of the sub-
jacent muscular tissue, and this alone must account for much of the
pulse acceleration, especially when it is not attended with a rise of
temperature. When actual inflammation of the muscle occurs, the
pulse is usually accelerated, and the increased rate persists. When
either the respiratory or the circulatory function is disturbed by the
pressure of the effusion, these disturbances constitute additional causes
of the quickened pulse-rate.
Disturbances of Cardiac Rhythm.-These consist either of
occasional intermittences, or of irregularities in the length of the revo-
lutions. They may occur in the early stage, in which case they usually
are only temporary, or later on, when they are due to either functional
exhaustion from pressure in impaired cardiac nutrition, or to advanced
inflammation or degeneration of the muscular tissue. Irregularity in
the inhibitory function is also believed to be concerned in its causa-
tion.
Palpitation is often complained of, both in the earlier and later
stages. A marked peculiarity of this symptom is the pain induced
by each impulse. Closely related to this symptom there will be ob-
served-
Anxiety and Dyspnoea.-The anxious expression and pallor are
noticed in connection with the painful palpitation, as well as in the
dyspnoea of the later stage. The disordered respiration comes on
gradually. The pain at the beginning of the attack may itself induce
a quickened breathing, and an established inflammation extending
over the whole surface may excite marked reflex disturbances of both
the costal and diaphragmatic functions. As the effused fluid accumu-
lates, the respirations continue hurried and become deep and labored.
Gradually the accessory cervical and external pectoral muscles are
summoned to aid the intercostals and diaphragm, the anxious ex-
pression deepens, the chin is elavated, the alæ nasi dilate with each
inspiration, the eyes assume a glaring expression, and every move-
ment betrays the intense craving for air which the lungs, however effi-
cient in themselves, can no longer supply to the asphyxiated tissues.
Usually, the patient is unable to breathe at all when in the recumbent.
posture, and particularly when lying supine or on the left side. Nearly
always, he sits leaning forward, except when the intense restlessness
prompts some change of position in the vain hope of obtaining relief.
One case is on record (quoted in Ziemssen) in which the only attitude
the patient could maintain with present safety was on the hands and
knees. If this condition continues, the skin becomes mottled, then
cyanotic; a cold clammy perspiration bathes the surface, evidences of
heart failure or of general collapse begin to manifest themselves, and
death comes to the relief of the patient. The dyspnoea may be due
to gradual loss of ventricular energy, resulting from the increasing
398
A SYSTEM OF MEDICINE.
pressure, or from inflammation or degeneration of the muscle-tissue,
or it may be due, in other cases, solely to pneumogastric irritation.
Orthopnoea is regarded by Paul as an important symptom. Bauer
(vide Ziemssen, vol. vi., p. 602) explains is as "specially due-in addi-
tion to the usual causes-to the fact that the mobile fluid lies more
unfavorably in the horizontal position of the body than in the sitting
posture," since in this position "it presses upwards and backwards so
as to exert considerable pressure upon the auricles and origins of the
large vessels. Moreover, the pressure upon the lungs is greater in this
position, and for the purpose of avoiding this effect upon the right
lung, the patient prefers to lie upon his left, rather than upon the
right side."
Syncope, or fainting fits, is not a very uncommon symptom in
connection with the development of the affection, and seems to be
associated with other evidences of irregularity in the circulation, and
when one portion of the surface is hot while another portion is cold.
Insomnia may perhaps, as some writers assert, be due almost ex-
clusively to the pericardial pain. It will be found, however, that in
this disease, as in the first stage of pneumonia and in incipient
typhoid fever, insomnia is often present, even in the absence of pain,
and is not unfrequently of a persistent and intractable type.
Cough, Hiccough, and Vomiting.-All of these may be present.
in the first stage; as a rule, however, the latter is most apt to appear
after serous effusion has taken place. The cough is usually short,
hacking, and dry, somewhat like that of an incipient bronchitis,
though at times accompanied with a viscid, frothy expectoration. The
hiccough is often obstinate and painful. It is excited evidently by
the inflammation to which the phrenic nerve is exposed in its passage
across the pericardial membrane to reach the diaphragm. Vomiting
generally occurs, when it occurs at all, in connection with the effusion
and the dyspnoea, but it is also met with where neither of these condi-
tions exists, and in cases in which it must be ascribed to influences
reflexly excited, or else determined by the same condition as that
which induces the singultus.
Renal Symptoms.-As a consequence of the elevated tempera-
ture on the one hand, or of the diminished cardiac energy on the
other, the renal excretion should be expected to exhibit marked
changes. The decrease in the aortic pressure, with the general venous
stasis, induces congestion of the kidney, and the presence of albumi-
nuria may be noted even where no nephritic complication has either
preceded or accompanied the pericarditis. It is now well understood
that the mere presence of albumen in the urine, under such circum-
stances, is not indicative of serious renal disease. Other changes are
also noted, particularly the lessened volume, the high color, and the
increased specific gravity of the excretion, and the brick-dust sediment
DISEASES OF THE ORGANS OF CIRCULATION.
399
deposited on cooling. One of the commonest signs of extensive serous
effusion anywhere is a falling off in the volume of the renal excretion,
accompanied, usually, by an increased desire for liquids.
Physical Signs.-Notwithstanding the well-marked character of
some of the subjective and objective symptoms already described as
occurring in the first stages of a pericarditis, no single one of them,
and no combination of them, can be regarded as conclusive evidence.
of the existence of the disease, unless corroborated by the presence of
physical signs, and especially by the friction murmur presently to be
considered. If any disease, even acute articular rheumatism, runs its
course without the development of this murmur over some portion of
the pericardial space, the supervention of pericarditis may well be
questioned, whatever the other symptoms may be.
The physical signs of a pericardial inflammation and effusion are
elicited chiefly by palpation, percussion, and auscultation. Inspection
and mensuration may also be resorted to as aids and as confirmatory
methods. The symptoms or indications, thus obtained, are pericardial
friction murmurs, diminution of intensity in the normal cardiac
sounds, abnormal prominence of the præcordial region, distension of
the intercostal spaces, increased mobility of the position of the apex
beat, depression of the apex beat, diminished energy of the impulse,
friction fremitus, increase in area of absolute dulness, increase in area
of relative dulness, change of location of dulness from change of
posture, etc. Some of these we will now consider.
Pericardial Friction Murmurs.-A pericardial friction murmur
in the earlier stage of the disease is the only pathognomonic symptom;
without it, the diagnosis remains subject to at least some doubt. The
murmur possesses quite a number of characteristics, and by means of
some one or more of these it can be with certainty distinguished from
endocardial murmurs or other thoracic sounds. It may be heard over
any portion of the pericardial triangle, and may be co-extensive with
it. It is both systolic and diastolic in point of time (there may be a
presystolic friction murmur at the base of the heart, due to the move-
ments of the auricles). It possesses the "to-and-fro" quality, conveying
to the ear the sensation of coming and going. It is superficial; it is in-
creased by pressure of the stethoscope. It is not propagated beyond
the border of the pericardial triangle (except at the lower border where
the solid liver conducts it for about one-half inch below the base line
of the triangle). It is varied by a change of posture.
According to the best authorities, the pericardial friction sound is
not caused by mere inflammation of the pericardial surfaces; its pro-
duction requires the fibrinous exudation. The varying timbre of the
murmur seems to corroborate this statement, and the fact that præ-
cordial pain, fever, rise of temperature, and increased cardiac excitation
often precede the friction murmur, is confirmatory evidence. The
400
A SYSTEM OF MEDICINE.
friction sound often begins at the base of the cardiac triangle, and
gradually extends upwards along the sternum. Sometimes it origi-
nates at the base of the heart and near the origin of the great vessels,
this being the portion of the serous surface at which fibrinous exuda-
tion so often begins. When the murmur has been fully established
by the extension of a diffuse fibrinous pericardial exudation over the
entire surface, it will be found quite easy to mark out its exact boun-
daries upon the surface of the chest, and when this is done it will be
seen that it coincides exactly with the boundary of the pericardial
space, as we have studied it anatomically, except that at its lower
border it overlaps it about half an inch, being propagated in this par-
ticular direction by the solid and sound-conducting left lobe of the
liver.
The murmur varies in quality from that of a faint abrasion to that
of a rough scraping or rasping. As it is often heard, it is described as
resembling the creaking of new leather (bruit de cuir neuf). There
may also be variations of the sound in various parts of the præcordial
region, depending upon differences in the character of the opposing
surfaces, and in the nature of the frictional movements. An important
peculiarity in the murmur-one which materially aids us in distin-
guishing it from a valvular murmur-is its long duration, not only
persisting during the systolic and diastolic action, but, as Skoda has
pointed out, prolonged into the intervening period, so as to cover
almost the entire period of the revolution. Occasionally, the sound
may be systolic only, or diastolic only. In such cases it is usually
longer than the systole or the diastole, as the case may be.
Pericardium murmurs can be modified by various causes. A change
in the patient's posture will often cause an increase or a decrease in a
sound already existing, or may even cause the appearance or disap-
pearance of a murmur. The manner in which these changes are
brought about is so obvious as not to require explanation. Again, we
have already mentioned that pressure over the præcordial space in-
creases the intensity of the friction murmur. A similar effect is often
noticed resulting from an intra-thoracic pressure during inspiration.
This has been usually ascribed to the increased friction between the
opposed surfaces from contraction of the diaphragm, though the lateral
increase in the volume of the lung tissue has always seemed to the
writer to be a far more reasonable explanation. It must always be
remembered that endocardial troubles are liable to occur in the prog-
ress of pericarditis, and that strong valvular murmurs occurring in
connection with those produced by the pericardium may sometimes
lead to a faulty diagnosis.
The discontinuance of the pericardial murmurs may occur in three
ways: first, by an accumulation of effused fluid, pressing apart the
rubbing surfaces; second, by the formation of adhesions, preventing
DISEASES OF THE ORGANS OF CIRCULATION.
401
frictional movements; and third, by the re-absorption of the fibrinous.
exudation. When its cessation is caused by the incoming serous effu-
sion, the sound usually diminishes first at the lower part of the præ-
cordial space, and the effect gradually extends upwards. Cases do
occur, however, in which the murmur is not entirely obliterated, even
by a quite extensive accumulation. As the effused fluid is re-absorbed,
there may be a return of the friction murmurs, though in much less
intense form.
Fremitus. When the friction is of a rough, rasping, or grating
quality, it gives rise to fremitus or thrill. The vibrations can be per-
ceived by pressing the fingers into the intercostal spaces, or by making
moderate pressure with the hand over the heart. The effect has been
said to resemble that produced by the crackling of parchment. The
patient should be in the semi-recumbent posture. It is much better
appreciated by the ear than by the sense of touch, the latter method
adding little, if any, to our knowledge of mechanical causes and con-
ditions of its production. It is by no means certain, even when we
would most expect to find it.
As the effusion of serum supervenes upon the condition which has
given rise to the pericardial friction murmurs and fremitus, the walls
of the sac are distended, the visceral and parietal layers separated,
and the two above-named signs are either greatly moderated in inten-
sity, or obliterated entirely. The presence of the effused serum, par-
ticularly if in large quantity, superinduces a new series of signs, of
almost equal diagnostic importance.
Protrusion of the Præcordial Portion of the Chest-wall.-
This sign is found to occur in cases of extensive effusion, and particu-
larly in quite young persons, in whom the parts are still soft and
yielding, although it may occur also later in life. Pericardial effusion
as an accompaniment of mollities ossium,-a not unlikely occurrence,
—will exhibit this condition in a marked degree. The effect is in all
cases produced by the pressure of the pericardial contents, and con-
sists in an outward convexity or arching of the costal cartilages, or in
chronic conditions, favoring it, even of the ribs also. In connection
with this change in the shape of the rib, there may be a lifting up of
the ribs affected, which will further increase the visible effect, and
which is easily ascertained by comparative measurements of the two
semi-circumferences of the chest. It may happen that the intra-
pericardial pressure is transmitted through the left lung to the general
pleural surface, and so cause a general elevation of the left ribs, almost
as in normal inspiration, and lead to the erroneous diagnosis of a
pleuritic effusion, a mistake that might be favored by the effect of the
pressure upon the percussion resonance of the lung itself. Neither
must it be forgotten that cardiac dilatation and hypertrophy are both
VOL. I.-26
402
A SYSTEM OF MEDICINE.
capable of producing the same præcordial protrusion as does pericar-
dial distension.
This change in the contour of the thoracic walls may be prevented
in several ways. The firmness of the ribs and cartilages may be too
great to admit of such a curvature taking place. Or the lungs may
yield to the lateral pressure sufficiently to prevent any great mechan-
ical effect from being exerted anteriorly, or adhesions may, by their
arrangement and strength, preclude the possibility of very great dis-
tension in that particular direction. The bulging, when it does occur,
is usually central at the lower portion of the præcordium, and between
the apex and the sternum.
Distension of the intercostal spaces has been noticed, though
it is not a constant symptom, even in the presence of an extensive
serous accumulation. It may result in weakening the affected inter-
costals, thus adding somewhat to the respiratory complications.
Increased fulness of the epigastrium is sometimes present.
It is caused by the depression of the diaphragm by the weight and
distending force of the fluid above. In connection with this sign,
there may be a slight downward displacement of the liver.
Increased Mobility of the Apex Beat.-The distension of the
pericardium admits of more free and extended movements of the
heart, and it is consequently found that changes of the posture of the
subject result in greater degrees of displacement of the heart than
when the sac is in its normal condition. Adhesions, however, may
operate so as effectually to prevent these changes in the position of
the apical impulse. When the diaphragm is much depressed, the
apex may be found as low as the sixth intercostal space.
Weakness of the cardiac impulse is observed in the great
majority of cases. It is due to two causes: first, the presence of the
fluid in large quantity, distending the sac and allowing the heart to
gravitate away from the chest-wall, and the intervention of the fluid
between the apex and the stethoscope; and second, the weakness of
the heart's action induced either by the pressure of the surrounding
fluid, or by other changes in its muscular tissue, occurring in connec-
tion with the pericarditis. Generally these two causes concur to pro-
duce the effect. This also may be prevented by certain fibrinous ad-
hesions, preventing the gravitation of the heart backwards from the
anterior wall of the thorax.
Increase of the Area of Absolute Dulness.-The serous dis-
tension of the pericardial sac, and especially the increase in its bilat-
eral diameter, presses back the overlapping edges of the lungs, and
thus increases the area of absolute dulness. When adhesion has
occurred between the pericardial and costal pleuræ, the increase of
the area will be more marked, but it often happens that there is little.
DISEASES OF THE ORGANS OF CIRCULATION.
403
change in the position of its outlines, even when the effusion is very
abundant.
Increased Area of Relative Cardiac Dulness.-This is a more
constant and, therefore, more reliable, indication than the preceding.
Even when the edges of the lungs are not displaced by the distended
sac, the deeper portion of the lungs may be forced aside to make room
for the encroaching fluid. In health, the cardiac dulness extends to
the left no farther than the extreme point of the heart; but when the
sac is stretched to its utmost with fluid, the dulness may extend far
to the left of the apex. When the area of relative dulness is found
thus protracted beyond the apex, it constitutes undoubted evidence
of extensive effusion. At the same time, the dulness is usually pro-
jected upward; it may be as high as the second rib, or may even ex-
tend higher yet toward the apex of the pericardial pyramid. From
this highest point the left border of what was once the pericardial
'triangle" now curves outward to, or beyond, the left nipple, to reach
the extreme limit of the area of dulness beyond the cardiac apex.
The right border may also be forced over even to the vertical mam-
millary line, and the "triangular" or pyramidal form of the sac no
longer exists. The distension downward is less marked.
((
How much fluid must be contained in the pericardium in order to
be discoverable by percussion, is a question exceedingly difficult to
Bauer estimates it at about 100 cubic centimetres (2.8 fluid
ounces). Yet he says, "many circumstances may conspire to render
this approximative measurement worthless" (Ziemssen).
answer.
Diagnosis.—In attempting to arrive at a positive diagnosis, which
shall include not merely the question of the existence or non-exist-
ence of pericarditis, but shall also embrace an adequate idea of the
special and characteristic features of each case, there are numerous
and serious difficulties to be encountered. Some of these difficulties
arise in the heart and pericardium, and some have their origin in the
lungs, pleuræ, and other neighboring structures.
The mere fact of the presence of pericarditis can usually be detected
by the frictional murmur alone, supposing always that the examina-
tion is made before adhesions or profuse serous exudation shall have
obliterated this important sign. Owing to the fact that pericarditis is
sometimes unaccompanied with high fever, pain, or any other alarm-
ing symptom, the attention of the physician may not be asked to the
case until even serous effusion begins to produce its distressing me-
chanical symptoms, and then it may be utterly impossible to detect
the slightest friction murmur. In such a case the diagnosis can
usually be made out, and the case distinguished from hydro-pericar-
dium-i. e., mere effusion without previous inflammation-by the his-
tory of the patient, which will, in most cases, show some pre-existing
disease likely to develop a pericarditis, together with either the pecu--
404
A SYSTEM OF MEDICINE.
liar weight or pressure over the præcordial region, or else the physical
signs which indicate pericardial adhesion or which hint at the pres-
ence of cardiac weakness. The sum total of the patient's symptoms,
even without the friction murmur, usually constitutes a picture dis-
tinguished from that of an uncomplicated hydro-pericardium. It
does not always happen, however, that the friction murmur is com-
pletely obliterated even by an extensive serous transudation of inflam-
matory origin, while in pure pericardial dropsy such a murmur is
never produced.
matter.
The diagnosis of the character of the exudation is quite another
True, the friction sounds indicate quite conclusively the
presence of a fibrinous exudation, and the discontinuance, partial or
complete, of these sounds, determines at once the fact of absorption,
adhesion, or serous effusion. As between these, the discrimination is
usually easy, percussion and palpation enabling us to determine the
presence or absence of effusion extensive enough to preclude the like-
lihood of pericardial friction, and the general symptoms of extensive
adhesions (to be hereafter described), helping us to decide between
the other two.
Hæmorrhagic and purulent accumulations may not give rise to physi-
cal, or other, objective signs of a distinctive character; yet we may
often obtain reliable data on which to base pretty confident conclu-
sions of the presence of blood or pus. If the primary morbid cause
of the pericarditis has been such as to favor hæmorrhagic exudations.
and extravasations, we shall rarely be justified in rejecting the diag-
nosis of blood accumulation without very clear contra-indications.
The diseases showing a special tendeney to produce the hæmorrhagic
form of pericardial exudation are morbus maculosis, scurvy, scarla-
tina, measles, and small-pox of the hæmorrhagic type, and the hæ-
morrhagic tendency in typhoid fever. Besides these, degenerative
diseases of the coronary vessels are far more likely to result in rupture
of the vascular walls during the continuance of a pericardial hyperæ-
mia or inflammation than at other times. The presence of pus in the
sac, inducing superficial destruction of the visceral surface, forms an
additional factor in the causation of pericardial accumulation of blood.
So, also, cancerous and tuberculous conditions should be mentioned
as causes of the same unfavorable complication. Absolute certainty
in the diagnosis is, however, exceedingly difficult of attainment.
The presence of pus in the sac is equally difficult to diagnosticate
with positive certainty. There are certain diseases, of course, in which
we should always suspect a purulent character in a supervening peri-
cardial effusion. Of these, pyæmia and the proximity of abscesses or
extensive ulcerations are formidable examples, and it is well known
that the liability to purulent transformation of the fibrinous or fibri-
no-serous exudations is much increased by a lengthened period of in-
DISEASES OF THE ORGANS OF CIRCULATION.
405
flammatory action. In Ziemssen, vol. vi., p. 608, special attention is
called to the fact that in this last-mentioned condition we are likely
to find also evidences of cardiac muscular enfeeblement. There are
no special physical signs indicating that the pericardial contents are
purulent in character. Where the fluids become ichorous in character,
we may have subsequent symptoms of general blood involvement.
The liability to confound the increased area of dulness with that
produced by cardiac hypertrophy is not very great, except when the
effusion is not abundant. An extensive effusion presents an outline
of dulness not at all resembling that of a hypertrophied heart. The fee-
ble apex-beat, its frequent disappearance when the patient lies supine,
and, perhaps more than all else, the rapid supervention of all these
signs, as against the slower and more gradual appearance of a hyper-
trophy, form quite conclusive elements of diagnostic distinction.
In collapse of the tissue of the lungs the overlapping edges will be
retracted, the anterior surface of the heart more extensively uncovered,
and the area of absolute dulness increased correspondingly. This
condition may be mistaken for a pericardial effusion with displace-
ment of the pulmonary borders. But a collapse of the lung would
also cause a lifting of the diaphragm by atmospheric pressure, and an
elevation of the cardiac apex--a condition of things which, in an ex-
tensive pericardial effusion, is likely to be reversed. If the edges of the
lungs be immovable, owing to pleuritic adhesions, the pericardial disten-
sion cannot cause any extension of the absolute dulness, but the area of
relative dulness can still be enlarged. This is one of the reasons why
expert diagnosticians usually rely more upon the relative than upon
the absolute dulness. But probably the complex problem of all is
present when left pleuritic and pericardial effusions coexist. In such a
case the counter-pressure in the left pleural cavity may prevent the dis-
tension of the pericardium in that direction, and both it and the heart
may be forced over to the right. The displacement of the impulse and
of the sounds and murmurs will then have to be taken in connection
with all the other signs and symptoms in an attempt to form what
must, in such cases, be an uncertain diagnosis, unless the pericardial
distension to the right should be sufficient to reveal the true condition.
Differentiation between endocardial and pericardial murmurs ought
not to be very difficult, even an endocardial double murmur (¿. e., a
systolic and a diastolic murmur combined) does not convey to the
ear the sensation of a "to-and-fro" movement like the sound of peri-
carditic friction. Moreover, these valvular sounds are not increased
by pressure, not modified by changes of posture, and not heard with
equal distinctness over every part of the præcordial region. Again,
one or both elements of the endocardial double murmur may be trans-
mitted beyond the pericardial space, along the course of the great
vessels, while the pericardial murmur is not.
406
A SYSTEM OF MEDICINE.
Prognosis. Previous to the discovery of the physical signs of peri-
cardial inflammation, the disease was thought to be of a most for-
midable nature, the fact being that the character of a large proportion
of these cases which terminated in recovery was not suspected. In
more recent times it is known that the percentage of mortality is not
high, and that many of the unfavorable cases owe their fatality either
to the primary disease or to a condition that originated the pericarditis,
or to some complication of the secondary disease, rather than to the
pericarditis itself.
In nu-
We have already stated that the disease may terminate without
passing beyond the stage of fibrinous exudation. It is, indeed, likely
that it can come to a favorable end with the hyperamic stage and
without even an exudation of any kind, though, of course, this is a pro-
position not easy of demonstration because a mere hyperæmia could
not be diagnosticated with certainty, since it gives rise to no physical
signs, and because its subsidence would leave no abnormalities to be
discovered in a subsequent post-mortem examination. But when the
disease establishes itself firmly, even then it may run its course and
terminate in a few days, or at most in a month or six weeks.
merous cases, however, the complications are such that a longer period
must elapse, ere all the parts involved can be restored to their original
integrity. The cases which terminate in recovery within two or three
weeks are those only in which the fibrinous exudation has not been
very abundant, since the re-absorption of this substance cannot be so
rapid as is sometimes the case with the serous effusion. It is not un-
common to have such cases recover completely, if we may judge by
the disappearance of all the symptoms, in a period of from one to two
weeks. These favorable cases include those which occur in the course
of acute conditions, as articular rheumatism, uncomplicated scarla-
tina, and other eruptive diseases, pleurisy, etc., though so speedy and
favorable an issue is not to be expected in all such cases. The begin-
ning of the absorption process is often accompanied by a rise in tem-
perature, and, in case of a rapid absorption of serous fluid, an increase
in the volume of urine.
The direct causes of a fatal termination are quite varied in char-
acter. The general tendency, so far as the mere inflammation is con-
cerned, is towards recovery, except in the presence of extreme debility
from some other cause. But a very extensive effusion may cause dan-
gerous disturbances of both respiration and circulation, simply by
reason of the mechanical pressure. The more direct manner in which
this is accomplished is by preventing cardiac diastole, and thus in-
ducing venous congestion; by compression of the lungs, interfering
with both the air-supply and the blood-supply to that region; and by
diminishing the aortic pressure, with consequent debility, or actual
degeneration of the cardiac muscular tissue, with, sometimes, sudden
DISEASES OF THE ORGANS OF CIRCULATION.
407
heart-failure. There are other ways in which the fatal result may be
brought about less directly, though, in a certain class of cases, with
scarcely less certainty.
Probably the most dangerous complication, as well as one of the
most frequent, is direct involvement of the myocardium in the morbid
process. This, however, is rather a part of the disease than a mere
complication. In these cases the unusual excitation of the hyperæmic
stage may be followed by inflammation of a high grade, with rapid
and fatal degeneration. This danger must be a factor in the prognosis
of every case of pericarditis, and when it does not immediately result
in death, it very frequently runs into chronic forms of heart disease,
from which complete recovery is well-nigh impossible and a long lease
of life at least very improbable.
Other dangers in the course of the disease are the liability to hæm-
orrhage and to purulent inflammation. The first-mentioned complica-
tion may occur rapidly, the patient succumbing speedily. The causes.
of these dangerous hæmorrhages have been already mentioned. Or
the exudation may itself be hæmorrhagic, due to a scorbutic influence
or to the nature of the primary disease, as heretofore described. When
the exudation is purulent in character, death usually follows quite
speedily, although not in all cases. The cause of the purulent condi-
tion, however, must sometimes be recognized as exercising a large in-
fluence in bringing about the fatal termination. Of this we may find
a striking illustration in puerperal pyæmia, or in diffuse and extensive
pulmonary or hepatic abscess.
When pericarditis takes on a chronic form, as it not unfrequently
does, particularly when the primary cause is itself of a chronic or con-
stitutional nature, the prognosis is always unfavorable. True, the
finale may be long deferred, but the disease runs a course which per-
petually keeps the patient in imminent danger. The exudation of
serous fluid sometimes increases and diminishes alternately and
repeatedly. If exudation of a fibrinous character exists, adhesions
may be multiplied, and through all the process purulent and hæmor-
rhagic complications may occur at any time. In addition to this,
myocarditis and myocardiac degeneration commonly follow, and from
this, heart-failure may suddenly cut short the wearisome history at
any moment. Or, dilatation, with compensatory hypertrophy, may
follow upon chronic pericarditis, with all their train of morbid changes,
sufferings, and dangers.
The prognosis then must be based upon a variety of considerations.
First, upon the primary cause of the attack. If it be a scorbutic or
hæmorrhagic diathesis, or if it be tuberculous, or carcinomatous, or
suppurative, or pyæmic, the prognosis can rarely be favorable. If, on
the other hand, the attack should be of acute rheumatic origin, or due
to some other acute, but mild and uncomplicated, disease, the general
408
A SYSTEM OF MEDICINE.
A
prognosis is favorable. Secondly, the extent of the inflammation.
circumscribed pericarditis, especially if not extensive, is not usually
considered a cause of great anxiety unless complicated with some
other condition of more dangerous tendency. A diffuse inflammation,
on the other hand, is likely to result in more extensive effusion, and
consequently in greater danger from mechanical pressure. Thirdly,
the character of the exudation. Thus the fibrinous form is not unfa-
vorable, unless extensive adhesions or purulent transformations com-
plicate the condition. The serous form is probably equally favorable,
its unhopeful element consisting in its volume rather than its quality.
The hæmorrhagic form requires an unfavorable prognosis when it is
the natural outcome of a grave primary disorder, as it usually is.
When depending on rupture or erosion of vessels, its unfavorable
character will largely depend upon the quantity of blood escaping into
the sac. The purulent form demands an unfavorable prognosis always.
Fourthly, the complications. These are not of necessity unfavorable
indications, though they always add to the anxieties and perils of the
cases. There is one complication which always renders the case dan-
gerous, and its recovery a matter of the gravest doubt; viz., myocarditis
or myo-degeneration. Fifthly, the age of the patient. Diffuse pericar-
ditis occurring in infancy or in old age is exceedingly dangerous. In
infancy, the cases are usually fatal; in old age, not unfrequently so.
The period of least danger is said to be in early adult life.
THE TREATMENT OF PERICARDITIS.
BY E. M. HALE, M.D.
I must premise by saying that, as pericarditis is generally of rheu-
matic origin, the treatment, to a large extent, is that of rheumatism.
But if we confine our efforts to the treatment of rheumatism alone, we
shall not be able to cope successfully with the condition of the heart
caused by it.
There are, then, two indications to be met:
(1.) To remove the rheumatic inflammation.
(2.) To retain the power of the heart.
To meet the first indication, the following remedies are indicated:
Aconite, Belladonna, Bryonia, Cimicifuga, Francesca (Manaca), Col-
chicum, Kali iod., Spigelia, Squilla, Ranunculus, Verat vir., and
Sulphur.
To meet the second indication, the true cardiac remedies,—which
have no influence on the rheumatic condition,-namely: Digitalis,
Convallaria, Adonis, Cactus, Caffein, and Coca, are most useful.
The first and most essential indication in rheumatism is rest, as ab-
DISEASES OF THE ORGANS OF CIRCULATION.
409
solute as possible. Joints and muscles in a state of absolute rest
recover sooner than when motion is permitted. The heart cannot be
put into a condition of rest. It must move; but we can greatly restrict
its movements by enjoining complete bodily and mental quiet, and
the use of certain remedies. The whole body can be kept quiet, by
our personal influence in advising the patient, and giving reasons for
such advice. Joints and muscles should be enveloped in raw cotton,
and sometimes rendered immovable by splints.
I have rarely found the use of external applications of any value in
rheumatism. Warmth from hot water, poultices, hops, etc., sometimes
seems grateful to the patient, but the "liniments," made of strong oils
and irritants, should not be allowed. If medicinal substances are ap-
plied, they should be made of the medicines useful in each case.
Lotions of Aconite, Belladonna, Bryonia, or Opium can be prescribed.
Alkaline lotions have been lauded, and even acid embrocations have
been praised. (Fuller strongly praises diluted vinegar.)
Aconite is one of the most useful remedies for pericarditis. Its symptoms are
closely similar to the acute form of the disease. If used in the rheumatism which
precedes it, the cardiac inflammation will often be prevented. Its chief indications
are the high fever, high temperature, rapid and strong action of the heart, hard, wiry
pulse, quick, 130 to 150, the great restlessness, mental anxiety, quick, anxious respira-
tion with oppression of the chest. In this stage Aconite should be given in the 1×
dilution until the restlessness and anxiety and temperature are lessened, and then
changed to a higher dilution, 3 to 6*, when the following symptoms obtain: the beats
of the heart become weaker, irregular, intermitting, or unequal, and at the same time.
the pulse is small feeble, slower, and not synchronous to the beats of the heart; the
temperature is lower, while the respirations increase. These symptoms (says Bæhr),
are peculiar to Aconite, and occur only in diseases of the heart. If, however, Aconite
does not remove these symptoms of impending heart-failure in a short time, it will be
necessary to resort to Digitalis or some other true cardiac remedy.
Digitalis has symptoms closely resembling those of Aconite, but they do not
occur in the same order of sequence. Digitalis primarily increases the tonicity and
force of the heart until it causes its death in tetanic contraction. Aconite excites and
irritates the heart (primarily) until it causes death from paralysis in diastole. I do
not believe that, practically, Digitalis is of any value in pericarditis, in its primary
inflammatory stage, for it does not cause inflammation of the heart. In the article on
Endocarditis I have fully given my views of the sphere of action of all the cardiac reme-
dies. Suffice it to say in this place that Digitalis is useful only when the muscular
power of the heart is failing, and when Aconite fails to afford relief. It is indicated
by the irregular and unequal and intermittent pulse, the excited but weak action of
the heart (which often simulates force, but is not), the rapid respiration, oppression
of breathing, cyanotic appearance of the face and lips, and a general venous stasis.
In this condition only the 1* dilution, or 1* trituration of the leaves, is of any value,
and these, in quantities of 5 to 10 gtt. or grs., must frequently be repeated, until de-
cided improvement sets in.
Bryonia is, next to Aconite, the most useful remedy in pericarditis. No
remedy so closely resembles in every particular the rheumatic diathesis (as pointed
out by Dr. Rutherford Russell). It has a specific affinity for serous membranes; it
causes the acid condition of the blood; it causes all the pains so characteristic of rheu-
matic fever, and the products of the rheumatic inflammation (serous and plastic effu-
sions). We do not find in its pathogenesis the symptoms of pericarditis as fully
pictured as those of pleurisy, nor is it necessary. It corresponds to the pathological
condition, and that is often a better indication than symptoms. The "stitching," stab-
bing pains need not be present, for, as in some cases of pleurisy, they are notably
absent. The severe frontal headache, the inflammation of joints, the scanty, acid
urine, the acid sweat, the aggravation from motion, and often the gastric symptoms,
410
A SYSTEM OF MEDICINE.
thirst, dryness of the mouth, and brown coating of the tongue, are the leading indica-
tions.
Belladonna may be indicated in the acute stage by its well-known symptoms,
but especially by the cerebral congestion, the delirium, the congestion of capillary
system, etc.
Colchicum is indicated in cases having an undoubted rheumatic or gouty
origin. Recent experiments show that poisoning by Colchicum develops symptoms
very similar to rheumatism or gout. It causes many symptoms similar to Aconite and
Bryonia. The old school have nearly abandoned its use on account of the injury and
prostration caused by the drug. But we can take its symptoms and pathology and
prescribe it in small doses with benefit. The following symptoms appear to me to in-
dicate it. The fever is not high, and is attended by perspiration, hot moist skin, and
throbbing of the vessels, but the heart's action is weak, and the pulse is intermitting
and quick. There is also vomiting and purging, with coated tongue and thirst. In
some cases of rheumatism the poison appears to attack the intestines, and causes all
the symptoms of dysentery (enteritis). I have known several cases to occur during
pericarditis. Here Colchicum would be clearly indicated.
Asclepias tuberosa has many symptoms which indicate it in subacute
pericarditis.
Ranunculus.-All the species have in their proving many symptoms which
point to their probable usefulness in rheumatic affection of the heart.
Veratrum viride.-This powerful remedy is often indicated for a short time
at the onset of pericarditis in plethoric persons with large muscular development and
rigid fibre. The action of the heart is very violent and forcible, lifting the chest with
great, heaving pulsations. The lungs and brain are actively congested, cerebro-spinal
congestion is present, the pulse is hard, full, and bounding. In such cases from one to
five drops of the tincture every hour, meanwhile closely watching its effects, will often
bring on a favorable crisis. I think it a better remedy in idiopathic than in rheu-
matic pericarditis. As soon as the violent action of the heart, and the cerebral and
pulmonary congestion and high temperature, are relieved, substitute for it Bryonia,
or some other indicated remedy. Veratrum viride also corresponds to another stage
of the disease, rarely met with, it is true, but sometimes seen. The pulse becomes
very slow and full; synchronous with the heart's action; vomiting, great weakness;
movement does not quicken the pulse much; violent clonic spasms. Here a few drops
of the 31 every hour will soon bring up the pulse to its normal standard.
Verat. alb. has been recommended for "violent dyspnea, constricted sensa-.
tion in the throat, short dry cough, convulsive motions of a clonic character, cold
perspiration, and great thirst; tumultuous but weak action of the heart, with weak,
irregular pulse." These symptoms indicate paralysis of the heart, a condition in
which I should feel safer in prescribing CAFFEIN.
Francesca uniflora ("Manaca").-This remedy, which comes to us from
Brazil, is well worthy our careful study and thorough investigation. It has long had
a place in the Brazilian Dispensatory, and is largely used in domestic practice among
the Spaniards and the aboriginal tribes. Early travelers mentioned this "wonderful
specific" for acute and chronic rheumatism, and recount its magical effects upon them-
selves. It is used largely to-day in the hospitals of South America, and, of late, in
those of New York and Philadelphia.
"
It seems, from a study of its effects, and a few pathogenetic symptoms, to resemble
Bryonia and Cimicifuga. It causes intense headache, like a band around the head,
with symptoms of cerebral congestion; pain in the back of the head, neck, and spine,
of a lancinating, sticking character; aching terribly all over, with great heat over the
body, followed by profuse sweat, with subsidence of all the sufferings." These effects
are from large doses of the decoction, such as is used by the Indians, and large doses
of the fluid extract, prescribed by physicians. The group closely resemble an acute
attack of rheumatism.
Allopathic physicians, on this account, assert that it is contra-indicated in acute rheu-
matism, and because they cannot believe that small doses will cure. They claim it is
much more successful in sub-acute and chronic rheumatism, probably because aggra-
vations from the drug are not as common. Those interested in a study of the remedy
I refer to the Therapeutic Gazette (Detroit, 1881, 2, 3 and 4).
My own experience fully confirms the claims for its great power and efficacy. I
know of no remedy whose action is so prompt, certain, and curative. It not only alle-
viates the pain in a few hours, but prevents its return, and the extension to other joints
DISEASES OF THE ORGANS OF CIRCULATION.
411
and tissues. Our treatment of rheumatism has not been such as to shed much lustre
on our school, but with a judicious use of Manaca, and its sphere better defined by
provings, we shall be able to reach greater success in this disease. In acute cases
the dose I have found successful is a teaspoonful of a solution made by mixing one
drachm of the tincture to ten ounces of water, repeated every hour or two.
In chronic cases, marked by stiffness, lameness, and great pain on sudden or con-
tinued motion (contra Rhus), the dose can be varied from five drops of the tincture to
five drops of 1x dilution, every two or three hours. I expect brilliant results from it
in rheumatic affections of the heart.
Cimicifuga, owing to its specific affinity for muscular tissues, should be better
indicated in rheumatic myocarditis than in pericarditis. But it certainly has some af-
finity for the serous membranes, for it has been used successfully in all forms of rheu-
matism of the joints as well as the muscles. In medicinal doses it favors the elimination
of urea. It is considered to be particularly indicated when the rheumatic attack is sud-
den and severe. The fever is not high, but the pain is intense. There is excessive im-
pulse of the heart over a large space, with increase of dulness on percussion. The pain
in the heart is diffused all over the left side, and extends down the left arm. The
headache is peculiar, a sensation of bursting as if the top would fly off, with violent
aching in the eyeballs (Spig.). The heart's action is not only violent, but irregular
(choreic). Great depression of spirits, gloomy and taciturn. The pains are described
as aching, stitching, benumbing, or coming on in sudden shocks. I think it has no action
on the effusion of plastic material or serum, like Bryonia. I advise the lowest dilu-
tions.
Kali byd.-The Iodide of potassa is useful only during the period of effusion,
when the rubbing sounds are present, or when serum is rapidly collecting. It is indi-
cated in the great dyspnoea from excess of tough bronchial secretion or pericardial ef
fusion. I have seen the best effects from the iodides when given alternately with Dig-
italis. It is indicated in weakness of the cardiac muscle, from embarrassed action
owing to pressure from effused fluid. The Iodide of ammonium is often more active
than the potassium salt. In order to get its specific action, it must be given in doses
of at least five grains every four hours. In some cases I have found it to act better
in alternation with Convallaria than with Digitalis. Sulphur follows Kali iod.,
and
rivals it in pericardial exudations.
Kalmia latifolia has not been used in pericarditis rheumatica as much as it
merits. It is a remedy but little inferior to Aconite in the inflaminatory stages. It
causes tumultuous, rapid, and visible beating of the heart; paroxysms of anguish
about the heart, dyspnoea, fever, stitches, and rheumatic pains in the region of the
heart. It is not known to have any influence over the exudation, and in this as well
as other respects resembles Cimicifuga.
Squilla is a remedy little known in cardiac diseases, but one destined to occupy
an important place in their treatment. It has a decided affinity for serous mem-
branes, causing inflammation and exudation of lymph and serum. A study of the
incomplete pathogenesis given us by Hahnemann will show symptoms surprisingly
like pleuritis and pericarditis. Cases of poisoning show a still greater similarity. Its
botanical relationship to Convallaria and Lilium tig. is quite suggestive.
Spigelia should not be neglected in pericarditis. It is best indicated in the non-
rheumatic variety. Its symptoms must be studied by consulting its pathogenesis, and
are too extensive to be given here. Lilienthal, in his Therapeutics, gives the best re-
sumé of its cardiac symptoms.
The indications for the use of the true cardiac tonics are given under
endocarditis. They are to be used always in connection with the
rheumatic remedies, when the pericarditis is of rheumatic origin. It
is seldom that they are of great value alone, except in the later stages
of that malady. They have no influence over the inflammation, none
to arrest exudation or to remove the collection of serum (or hydro-
pericardium). They act solely on the nervous supply of the heart,
and govern its movements, regulating its rhythm, imparting strength to
its pulsations, and enabling it to overcome the tendency to failure or
cardioplegia. They remove the local and general dropsy solely by
412
A SYSTEM OF MEDICINE.
increasing the blood-pressure in the arteries, and by removing the
venous stasis. They are not specific diuretics, but cause the dropsical
effusions and infiltrations to be carried off by the kidneys, only by
acting on the heart and through the circulation.
It sometimes happens that all remedies fail to remove the serous
effusion in pericarditis. In such desperate cases paracentesis has
been resorted to with success. The operation has been performed with
good results by several surgeons of both schools. Full directions for
this procedure are to be found in the latest treatises on surgery.
HYDROPERICARDIUM.
BY PEMBERTON DUDLEY, M.D.
Synonyms. Hydrops pericardii; Hydrocardium; Pericardial
dropsy; Dropsy of the heart; (French) Hydropericarde; (German)
Herzbeutelwassersucht.
It is only in comparatively recent times that hydropericardium
has come to occupy a place entirely distinct from that of the serous
exudation of pericarditis. Now it is well known that it is a purely
mechanical transudation of serum from the pericardial sacs, occur-
ring independently of inflammatory action, not due to an altered
condition of the serous surface, but to an altered intravascular pres-
sure.
The pericardial sac is nearly always found to contain a greater or
smaller amount of serum, the quantity varying from two and a half to
three and a half fluidrachms (Flint). It may, however, be increased
to two or three ounces, as will be presently shown. It is held by
some recent authorities that no accumulation of this fluid exists nor-
mally during life, and that the entire quantity found in the sac is
transuded during the death agony or subsequently, and the fact is
cited that the longer the autopsy is deferred, the greater will be the
accumulation of fluid. While there can be no doubt whatever that
the prolongation of both the death agony and the delay of the autopsy
appear to have a decided bearing upon the quantity of pericardial
fluid found, yet we do not by any means accept the view that all this
fluid is thus produced. Colin and others found a greater or less.
accumulation in all their cases of animals experimented upon, in
which the observations were made either immediately subsequent to
instantaneous death or during life. The quantity found in the peri-
cardial cavities of horses, opened immediately after death from hæmor-
rhage, varied from two and a half to three and a half fluid ounces.
Here the conditions above mentioned, to which the presence of peri-
cardial fluid has been ascribed by recent authorities (Bauer, vide
DISEASES OF THE ORGANS OF CIRCULATION.
413
Ziemssen, vol. vi., p. 665), namely coronary venous stasis and post-
mortem transudation, are entirely eliminated. Another argument
against the view advanced by Bauer, and others, is found in the pres-
ence of correspondingly large quantities of fluid in other serous cavi-
ties opened during life by accident or in the course of surgical opera-
tions, such as the synovial sacs, the cavity of the tunica vaginalis, etc.
We are disposed to accept Flint's estimate of the quantity present
during healthy life, viz.: two and a half to three and a half flui-
drachms, as approximately correct, and the addition of even a much
larger amount, one to three fluidounces, as generally due to conditions.
accompanying or following the death agony, and not usually to be
regarded as evidence of a pericardial dropsy, as that term is ordi-
narily employed. It should be mentioned here that there are par-
ticular forms of death in which transudation is more rapid than in
others, among which suffocation or asphyxia, valvular diseases of the
heart, pneumonia, etc., may be specified.
Etiology.-Hydropericardium is never a primary disease, but is
always a mere symptom of some other morbid condition. It may be
either part of a general dropsy, or a localized effusion, dependent on a
locally acting cause. When it comes on as part of a general dropsy, it
is most frequently in those cases which result from cachectic troubles,
as from hydræmia arising from any cause, but especially from Bright's
disease. When it constitutes a purely local symptom, it is usually
produced by stasis in the coronary veins, or by atheromatous disease
affecting the coronary arteries. It has been suggested that it may
occur in consequence of collapse or shrinkage of any of the intra-
thoracic viscera, the change of volume generating a vacuum which is
filled by transudation from the pericardial vessels superinduced by
atmospheric pressure. This opinion, however, is not well sustained.
Symptomatoloy and Diagnosis. From what has been said
respecting the symptoms and diagnosis of pericarditic serous effusion,
there are numerous conditions arising in the course of a true hydro-
pericardium which scarcely need special discussion. The presence of
the fluid is probably never detected during life, unless it accumulated
to a considerable amount. When the discovery of its presence is
finally made, one of the first questions which forces itself upon the
medical attendant is whether it is a purely dropsical effusion or a
serous exudation which has occurred in the course of an undiscovered
pericarditis. If the physician's previous examinations of the case
have been such as to warrant the conviction that the effusion has not
been preceded by a frictional pericardial murmur, the question of its
character is not very doubtful. The careful physician, however, will
inquire further as to the previous occurrence of præcordial pains or
pressure, fever, etc., and particularly as to the pre-existence of acute
rheumatism, or other disease likely to induce secondary pericarditis.
414
A SYSTEM OF MEDICINE.
The absence of these indications will fully justify a diagnosis of hydro-
pericardium.
The physical signs are almost exactly like those observed in the in-
flammatory form of pericardial exudation. As the fluid accumulates,
the area of absolute, and that of relative, cardiac dulness on percussion
are both increased. The pressure or weight of the fluid depresses the
diaphragm and interferes with its movements, and diminishes cor-
respondingly the freedom of respiratory movement in the abdominal
muscles. There is also a striking difference in the præcordial dulness
in the sitting and recumbent postures, the fluid in the latter position.
gravitating toward the posterior portion of the thoracic cavity, and
permitting the borders of the lungs to encroach farther into the præ-
cordial region. While in the sitting posture, the fluid changes its
position and presses the edges of the lungs backward. The apical
impulse presents changes similar to those described under pericarditis,
i. e., it loses its force in two ways: first, by the intervention of fluid
between the heart and thoracic wall, and, secondly, by the enfeeble-
ment of the heart's action, due to mechanical compression, and the
obstruction to the supply of venous blood to its cavities. There is
also a marked pulse-symptom-a diminution in the height of the
pulse wave, caused by the diminution of the venous supply and the
cardiac debility. We must also mention as common signs venous
engorgement, cyanosis, and diminished renal excretion, often attended
with thirst and without fever. There are also the same respiratory
and reflex symptoms as in extensive pericarditic exudations; viz.,
dyspnoea, orthopnoea, anxiety, nausea and vomiting, etc. The in-
tensity of some of these symptoms will be modified greatly by the
rapidity of the effusion; the slower the fluid accumulates, the less
severe will the symptoms usually be. Finally, as to the physical
signs, it must be said that they are more constant in hydropericardium
than in effusion following pericarditis, in all those particulars in which.
they can be modified by adhesions, since this latter complication is
not liable to arise except in the presence of inflammation.
Prognosis. It is usually the case that hydropericardium arises
from disease of a grave and incurable character, and hence the prog-
nosis is in all such cases unfavorable. When the dropsy occurs in
connection with a general dropsy, the prognosis will of course be un-
favorable, since in almost all such instances the pericardial complica-
tion does not supervene until the preëxisting condition has rendered.
the case almost hopeless. In pericardial dropsy caused by hydræmia
from parenchymatous nephritis or other forms of kidney disease, grave
apprehensions are to be entertained.
Fortunately, the cases are not all of so grave a nature. Many in-
stances occur in which a perfectly curable hydræmia may give rise to
a pericardial dropsy, and in such cases there is every probability that
DISEASES OF THE ORGANS OF CIRCULATION.
415
when the primary cause is cured, or has otherwise ceased to exist, the
dropsical fluid may be reabsorbed, and that this favorable process can
be hastened by appropriate treatment. The same statement can be
made respecting hydropericardium resulting from diseases of adjacent
organs, as the lungs, liver, etc., the question of recovery depending in
these cases largely upon the character and the duration of the pri-
marily acting cause.
*
The treatment of dropsy of the heart is in all respects the same as
the treatment of serous effusions as the result of pericarditis.
It is therefore unnecessary to go over the same ground. Suffice it
to mention that the most appropriate remedies are doubtless Arsenicum,
Arsenite of Gold, Arsenite of Copper, Apis mel., Bryonia, Asclepias, Kali
carb., and Kali hyd. These are homoeopathic to the local effusion.
Should the condition of the heart be such as to induce general ana-
sarca, from failure of the functions of the kidneys, then we must use
Digitalis and its analogues whose properties, power, and method of use
are fully set forth in the article on Endocarditis.
HÆMOPERICARDIUM.
BY PEMBERTON DUDLEY, M.D.
Definition. Hæmorrhage into the pericardial sac.
We have already alluded to hæmorrhagic exudations in pericarditis.
arising from scorbutic diseases and others of a similar nature. Even
in pericardial inflammation of a less grave character, extravasa-
tions may take place from the newly formed vessels of the fibrinous
layer. We now come to consider, very briefly, hæmorrhage into the
pericardial cavity occurring independently of pericardial inflamma-
tion.
Hæmorrhage into the pericardium takes place, first, from wounds
penetrating the pericardium or the heart itself; secondly, from rupture
of the heart-walls, as from cardiac aneurism; thirdly, from aneurisms
of the aorta opening into the cavity; fourthly, from rupture of the
coronary vessels. Abscesses of the lungs may also, as already men-
tioned, open into the sac, and may, of course, discharge into it blood
as well as pus.
Pericardial hæmorrhage is usually and rapidly fatal. The sudden
abstraction of a considerable quantity of blood from the central organ
of the circulation is instantly felt in the nerve centres, and the quick
and energetic compression of the heart by the confined pericardial
blood, and the acute anæmia and paralysis of the cardiac muscle.
together make quick and terrible havoc with the vital functions. It
* By E. M. Hale, M D.
416
A SYSTEM OF MEDICINE.
may happen, however, that the accumulation of pericardial blood
takes place slowly, in which case the fatal result may be for a time.
deferred. If the patient fortunately survives the immediate effects of
the loss of blood and of the mechanical interference with circulation
and respiration, an inflammation of the serous membrane follows, with
death sooner or later, except when the hæmorrhagic effusion has been
quite limited, and does not recur.
A pericardial hæmorrhage will present the same dulness on per-
cussion as a serous effusion of equal extent. A sudden hæmorrhage
is not so voluminous as a more gradual serous effusion, simply because
the sac resists a sudden distending force, but gradually yields to a
more prolonged pressure. The hæmorrhage, therefore, even from a
cardiac or aortic aneurism, is not usually much more than a pint in
quantity. The prognosis in all cases is, of course, in the highest de-
gree unfavorable.
ADHESIONS OF THE HEART AND PERICARDIUM.
BY E. M. HALE, M.D.
"The discovery of adherent pericardium during life is in some cases
impossible, at least doubtful or difficult; but in others, and these are
amongst the most important cases, its existence may be ascertained on
reasonable and well-definable grounds.
Pathology and Diagnostic Points.-"When the adhesions are
partial, or when the heart, though completely adherent, is small, not
bound by external adhesions to the anterior walls of the chest, and is
covered to the natural extent by the lungs, their expansion being free
and unrestrained, thus the varying relations of the heart and lungs to
the chest is quite natural, and the diagnosis of the adhesions is im-
possible. If the adherent heart be enlarged, and is not attached to the
lower half of the sternum and the cardiac cartilages, by combined peri-
cardial and pleural adhesions, so that the action is automatic and the
passive or inspiratory movements of the heart are scarcely or but little
interfered with, the inspiratory expansion of the lungs is freely per-
mitted, and the diagnosis of the adherent pericardium may be difficult,
obscure or impossible.
When, however, the heart is, as usual, enlarged, being often affected
with valvular disease, the adhesions may be short, fibrous and bind-
ing; and the front of the organ may be affixed to the two lower thirds
of the sternum, and the adjoining cartilages by pleuro-pericardial ad-
hesions, so that the automatic and respiratory movements of the heart
and the inspiratory expansion of the lungs are restrained; thus the
discovery of the adhesions during life may generally be made by a
DISEASES OF THE ORGANS OF CIRCULATION.
417
ļ
careful study of the physical signs; its diagnosis being made more
firm and easy, in proportion as the heart is more enlarged, and more
firmly affixed to the anterior walls of the chest.
"When the adhesions are long and loose, and the heart is free from
valvular disease, and from any other influence tending to cause en-
largement of that organ, the size of the heart is usually natural.
"When pericardial adhesions are associated with valvular disease,
the heart is always enlarged.
“It is the natural effect of pericarditis for the inflammation to spread
from the pericardial to the pleural surface of the fibrous sac. When,
therefore, the pericardium becomes adherent to the heart in those cases,
it becomes adherent also to the walls of the chest as part of the peri-
cardium. These pleural adhesions often occupy an extensive space in
front of the chest, and may extend from the second left cartilage to
the sixth, from the manubrium to the upper half of the ensiform
cartilage, and from the right border of the sternum to the apex of the
heart to the left of the nipple line, as in the cases referred to in former
pages, and there described.
"When the adhesions are short and powerful, and when, being
pleuro-pericardial, they bind the walls of the heart extensively to the
walls of the chest in front of them, a great and constant strain is put
upon the ventricles; for they cannot contract upon themselves to
expel their contents, until they have dragged the sternum and car-
tilages powerfully inwards. The ventricles thus expend their force in
two directions, one towards the interior to expel their contents, re-
sisted in doing so by valvular incompetence, the other from the ex-
terior, to compel the part of the chest which is united to them like a
solid buckler to share in their contraction. Under these influences,
the ventricles tend to undergo a change in form, and to become flat-
tened out, the one in front of the other.
"When the adhesions, being extensive and pleuro-cardial, are not.
short and close, but of moderate length, and do not, therefore, bind
the sternum and cartilages to the heart like a buckler, they do not.
seriously embarrass the commencement action of the ventricles; but
during their contraction the ventricles begin at length to draw upon
the walls of the chest, and in the course of the systole they drag
these walls inwards.
"When the adhesions are, as usual, longer and less solid, the ven-
tricles contract more after their wont, and retain, more or less per-
fectly, their power. The right ventricle is usually enlarged as well as
the left, but not always, for the size of the ventricles is necessarily
influenced by the size of the valvular affection. When that affection is
mitral, or mitral aortic, the right ventricle shares the labor and enlarge-
ment with the left ventricle; when the aortic valve is alone affected,
the left ventricle is often alone enlarged; and when there is mitral
VOL. I.-27
418
A SYSTEM OF MEDICINE.
obstruction, the enlargement may affect merely the two auricles, that
of the ventricles being somewhat moderate.
"The ventricles, when the pericardium is adherent, tend to enlarge
outwards in every direction, and especially upwards to the manu-
brium, as well as downwards to the epigastric space, to the right and
to the left. The great arteries are lifted up on the top of the ventri-
cles into an unusual position, and are crowded into the narrow space
at the top of the chest, almost as high as the root of the neck.
"When the adhesions are dense, strong, and contracted, they sheathe
the whole heart in a tight, tough envelope, which grasps the auricles.
and ventricles, prevents their free expansion, and forcibly removes the
organ.
Symptoms. "A steady retraction of the lower half of the sternum.
during the whole of the systole of the ventricles, and the sudden.
starting forward of the lower half of the sternum at the beginning of
the diastole, with a return shock or blow, was observed in my own
case, published in 1844, and in one of Skoda's, given in 1852.
"A drawing inward of the cardiac intercostal spaces during the
systole was first observed by Heim, and afterwards by Dr. Williams,
by Skoda in three cases, and by Cejka in three more.
"This sign, which is sometimes present in other cases, renders the
existence of adherent pericardium probable, and especially if this sign
is still present when the patient draws a deep breath; but if it is fol-
lowed by a diastolic shock, the diagnosis of that affection is certain.
The existence, indeed, of a diastolic back stroke taken by itself pro-
nounces that the heart is adherent. A double movement of the sys-
tolic impulse, first forward with a heaving motion, then backwards
with a forcible retraction. The outward pressure, equal in every direc-
tion, of the blood contained in the ventricle during its contraction,
naturally forces forward the walls of the chest in front of it at the be-
ginning of the systole. During the continuance of the systole, the
adherent sternum resists the contractions of the heart, but in the
struggle the bone yields, and is drawn forcibly inwards by the active
ventricle. A non-diminution of the region of pericardial dulness and
of the impulse; an absence of change in the position of these signs
when the patient lies on the left side. This non-diminution of the area
of pericardial dulness and of this impulse is, undoubtedly, a valuable
sign of adherent pericardium; in one case, however, the impulse
below was exceedingly strong at the end of expiration, and in another
the upper and lower borders of the impulse probably descended
during a deep inspiration. This is indeed different from the diminu-
tion of the extent of dulness, and impulse, and, what is still more im-
portant, from a bodily transfer during a deep breath of the seat of the
dulness and impulse from the cardiac cartilages and the fifth space
near the nipple, to the epigastric region, including the ensiform car-
DISEASES OF THE ORGANS OF CIRCULATION.
419
tilage and the adjoining seventh costal cartilage; another case illus-
trates in its own manner the other point just referred to the non-
shifting of the seat of the impulse when the patient lies on the left
side.
"These, as far as I know, are the only signs of adherent pericar-
dium; but there are certain other signs, that, without ranking in pre-
cision with those just named, have their significance. The drawing
inward during the systole of the space between the ensiform cartilage
and the seventh costal cartilage was noticed by Sander in a case of
adherent pericardium; and in another case it was observed that the
tip of the ensiform cartilage was retracted during the contraction of
the ventricle.
"There is a great variation in the extent, force, character, and posi-
tion of the impulse in adherent pericardium. It may be imperceptible,
feeble, heaving during the systole, and very extensive; tumultuous,
and very irregular; strong, and very greatly extended either upwards
or downwards. Violent action of the heart has been observed over
the whole front part of the chest.
"The apex-beat is, as a rule, feeble, even when it extends from an
inch to an inch and a half to the left of the nipple line, being felt in
the sixth space.
Gairdner points to this restraint of the apex as a
probable element in the diagnosis of adherent pericardium. At times,
an extinction of the second sound is a unique sign of adherent peri-
cardium. The inspiratory movement of the abdomen at its centre was
equal to that at its sides; although in health the central movement is
from two to three times as great as the lateral movement of the abdo-
men." (Extracts from article on "Adherent Pericardium," by Francis
Sibson, M.D., F.R.S.)
As to the effects of adhesion upon the heart, we find the most con-
flicting opinions. Hope asserts that it causes hypertrophy with dila-
tation, others that it causes atrophy, while some authors assert that,
unless adhesions are very extensive, no change is caused. I find few,
if any, subjective symptoms recorded; if any, they are those which
we have in atrophy or hypertrophy.
The treatment, therefore, must be based on the condition of the heart.
If the heart is atrophied, its action will necessarily be weak; if dilated,
the same condition will be present. In the absence of subjective
symptoms, painful sensations, etc., we must select those cardiac tonics
which seem best adapted to each case. As a full account of such
remedies has been given under Endocarditis, the reader is referred
to that article.
If subjective, painful, or reflex symptoms are complained of, we
must consult the Materia Medica, and select the remedy which seems
best indicated by the symptoms. I have treated only two or three
cases in which I could, with any certainty, diagnosticate adhesions of
420
A SYSTEM OF MEDICINE.
the pericardium, and in these the symptoms were met by Arnica,
Cimicifuga, Rhus, Cactus, and Bryonia. Applications of Arnica and
Belladonna, in the form of either lotions or plasters, give some relief,
but as we are powerless to remove the adhesions, we cannot hope to
do more than palliate the unpleasant symptoms and preserve the force
and rhythm of the heart.
TUBERCULOSIS OF THE HEART.
BY E. M. HALE, M.D.
EXTRACT FROM ARTICLE BY THOMAS BEVILL PEACOCK, M.D., F.R.C.P., IN
REYNOLDS'S SYSTEM OF MEDICINE."
History. Laennec, when alluding to accidental products, says
that he had only three or four times met with tubercles in the sub-
stance of the heart, and when speaking of chronic pericarditis, he re-
marks that a tuberculous eruption may sometimes be developed in
the false membrane, and may thereby convert the acute into chronic
disease, as frequently happens in pleurisy and peritonitis, and he
states that he has met with two cases of the kind. In this passage,
Laennec indicates the form in which tuberculous deposits are found in
the heart; in one form they take place in the substance of the organ,
in the other on the surface, in connection with inflammation of the
pericardium. The former is certainly a very rare condition. Louis.
says that in 112 dissections of phthisical persons he did not meet with
a single instance of tubercle in the substance of the heart. Rokitansky
also speaks of the extreme rarity of the affection, and in the record of
116 post-mortem examinations of persons who had died of phthisis,
which I have analyzed, I do not find more than two or three cases in
which tubercle is said to have been found in the heart. The recorded
instances of such deposits being at all of serious importance are few
in number.
Pathological Anatomy.-The first writer who alludes to cases
of the kind is, I believe, Dr. Baillie, who, in his Morbid Anatomy, says
that he once saw two or three scrofulous tumors growing from the
cavity of the pericardium, one of which was nearly as large as a
walnut. They consisted of white soft matter, somewhat resembling
new cheese," and he adds that "the pericardium is a very unusual
place for any scrofulous affections ;" and in his dissections, in alluding
to the same case, he further says that both lungs were studded with
tubercles, and the right in a state of suppuration in places.
Tubercular deposits in the pericardium bear a close resemblance to
the similar disease of the arachnoid, pleura, and peritoneum. They
may be of very small size, mere specks, or may attain the dimensions
of a cherry-stone, filbert, or walnut. In consistence they are gener-
DISEASES OF THE ORGANS OF CIRCULATION.
421
ally soft, and they are usually of a grayish or yellowish color. The
deposits are situated beneath the serous membrane, and in some cases
masses are found more deeply imbedded in the substance of the ven-
tricles, and which were exposed freely on section. The tubercles in
the heart and pericardium occur under the same circumstances as
those which attend similar affections in other parts of the body; they
may be found in both sexes, at all ages, but more commonly in the
early part of life.
In several of the cases of tubercle in the pericardium the evidences
of the effusion had been observed during life. When such signs arise
in persons who are obviously tuberculous, and especially if they assume
the subacute form and are not attended by any large amount of liquid
effusion, there may be suspected a connection with tuberculous de-
posits. It must, however, be borne in mind that pericarditis, having
no relation to tubercle, may occur during the process of phthisis; the
inference as to the tubercular origin of such cases is, therefore, by no
means decisive.
Treatment.-It is evident that the treatment of tuberculosis of the
heart must be the same, in general, as the constitutional treatment of
tuberculosis. We cannot expect to cure such a condition, but we
have the means of giving relief to the patient, as in pulmonary tuber-
culosis, by the selection of those remedies which are indicated by the
subjective or painful symptoms.
CANCEROUS DEPOSITS IN THE HEART.
BY E. M. HALE, M.D.
This is of more common occurrence than tubercle.
The cases of cancerous deposits in the heart may be classed in four
series:
First. Cases of primary cancer, in which the disease exists only in
some part of the organ. They are of extremely rare occurrence.
Second. Cases in which the disease occurs coincidently and prob-
ably simultaneously in the heart and in different parts of the body,
and especially in parts adjacent to the organ. This form, though still
rare, is more common than the first.
Third. Cases in which the disease first appears in points adjacent to
the heart, the bronchial or mediastinal glands, the lungs, or the
glands around the larynx in the neck,-and thence spreads so as to
involve the pericardium and the large vessels at the base of the heart.
or the auricles. Cases of this kind are not uncommon, though less
frequent than those of the next series.
Fourth. By far the largest portion of cancerous disease of the heart
occurs secondarily to the deposit of cancer in some distant organ. Of
422
A SYSTEM OF MEDICINE.
forty-five cases analyzed, twenty-one were of this description, the
primary disease being situated in different instances in the eye, the
cheek and bones of the face, the lower lip, the breast and axillary
glands, the ribs and pleura, the abdominal organs, the inguinal glands,
the uterus, vagina, labia, penis, and testis, and the upper and lower
extremities.
The heart may be affected by cancer in different forms. Thus, of
the cases collected, seven are reported to have been cases of scirrhus,
four of melanosis, twenty-five of encephaloid. The deposit may
assume also the form of distinct masses or tubera, or it may be infil-
trated with the tissue, or it may occur on the surface.
Cancerous deposits in the heart do not appear to be generally pro-
ductive of any special symptoms by which their presence can be de-
tected during life. In some cases, where there was disease of the
adjacent organs, there were signs of pressure on the large vessels and
of interference with the circulation of the blood; and in three or four
instances the formation of the deposits on the surface of the heart
occasioned inflammation of the pericardium, which was recognized by
the usual signs during life.
Most usually, however, there are no symptoms by which the affec-
tion of the heart is indicated, and the condition is only detected on
post-mortem examination.
The treatment must be purely symptomatic and palliative, although,
if we are sure of our diagnosis, we may try Conium, Condurango,
Arsenic, etc.
D. DISEASES OF THE HEART MUSCLE.
BY E. M. HALE, M.D.
MYOCARDITIS.
Synonyms.-Carditis, Interstitial myocarditis; (French) Myo-
cardite; (German) Myocarditis.
Definition. Inflammation of the muscular fibres constituting the
walls of the heart, as an acute infection, with interstitial serous in-
filtration, and degeneration of the muscular fibres.
Varieties. The several attempts at classification which have been
made result in dividing this disease of the myocardium into the con-
ditions called acute and chronic; but the latter may be the same con-
dition as the growth of fibroid tissue, and will be included under that
head; while the former, though running a distinct course, may result
in a sub-acute or partial myocarditis, which has an indefinite course
and an indefinite result.
Ætiology.—The causes, even when the physician is confident of
DISEASES OF THE ORGANS OF CIRCULATION.
423
having made a correct diagnosis, are most often obscure. Myocarditis
may occur in connection with endocarditis or pericarditis, following,
and contemporary with, acute rheumatism, or independent of such.
affection; in the majority of cases the cause is too obscure to allow
of a definite statement. Whether cold, exposure, sudden and violent
exercise, or trauma, such as blows on the chest in the præcordial
region, may be exciting causes is by no means satisfactorily demon-
strated.
It occurs more frequently in males than in females, and generally
in persons under twenty-five years of age.
Pathology and Anatomical Characteristics.-The connective
and muscular tissues are both involved in most cases. When the
muscle alone is affected, use is made of the term parenchymatous
endocarditis. This inflamed substance is injected, swollen, softened;
extravasation is noticed, and it is pale and of a reddish-gray color.
The tissue may become degenerated, forming pus, which accumulates
in small masses, gradually leading to the formation of an abscess.
Leucocytes are found between the muscular fibres; sometimes the
inflammation, though moderate in intensity, is diffuse in extent, in-
volving the endocardium within, or the pericardium without. The
muscular fibres swell; fatty degeneration and atrophy follows, and
the case passes into the chronic condition, if the patient live. In the
case of the formation of an abscess there may be produced a fistulous
opening, pointing either outwards or inwards, or connecting two of
the cavities, or rupture may occur.
giving rise to fatal hæmorrhage.
hardened, encysted, or calcified.
The heart itself may be ruptured,
Sometimes the pus becomes cheesy,
A local inflammation is more common in the walls of the left ven-
tricle, near the apex, and rarely occurs in an auricle.
Symptoms. There are no positive symptoms of myocarditis ;
nothing certain can be ascertained beyond the fact that the heart is in
some way affected. Fothergill says: "Like all affections of the heart
wall, there is not a prominence of objective symptoms, and palpitation
is not usual, while the subjective symptoms are those common to all
cardiac failure." There are found restlessness, acute dyspnoea, pain
in the præcordium, palpitation, the heart's action growing irregular,
more frequent, and sometimes ending in complete failure. A corre-
sponding pulse is noticed. Pale, anxious, cyanotic countenance.
Distress of mind, sometimes delirium in young subjects; disturbance
of stomach, with vomiting (Quain). A sudden development of cardiac
weakness, after a transient stage of excitement. Sometimes all symp-
toms are wanting till the sudden outbreak which denotes a rupture.
Perhaps there may be found an increased area of cardiac dulness.
But taking it all in all, nothing can be ascertained during life beyond
the fact that there are signs of weakness in the heart.
424
A SYSTEM OF MEDICINE.
Diagnosis. With the present limited state of our knowledge,
myocarditis cannot be recognized with certainty. Its existence may
be suspected when the symptoms of cardiac weakness and failure
occur less sudden than in rupture, and more sudden than in cases of
acute degeneration, especially when pyæmia is present.
Cardiac abscess has never been positively diagnosticated.
Termination and Prognosis. As already stated, abscess and
rupture may result from the acute condition, or fatty degeneration
from the chronic. The prognosis is unfavorable, though recovery
may take place; it is, indeed, quite probable that in cases occurring
in connection with endocarditis or after acute rheumatism, recovery
frequently takes place.
Treatment. It is difficult to give a specific treatment for myo-
carditis because it is intimately connected, in the majority of cases,
with endo- or pericarditis. In cases of an idiopathic character, we
might find in Arsenic, Phosphorus, Lachesis (and other serpent poisons)
the nearest homoeopathic remedies.
Arsenic particularly causes rapid failure of muscular power, disintegration of
muscular tissue, and extravasations, etc., into the substance of the heart.
Phosphorus is nearly allied to Arsenic, causing abscesses, muscular paralysis,
hæmorrhages, emboli, etc.; also rapid fatty degeneration.
Lachesis and its analogues Naja, Crotalus, and others causes a very complete
picture of myocarditis, with all its essential symptoms. They are especially indicated
in cases due to pyæmia or septic poisoning.
If due to phlebitis, Hamamelis would be strongly indicated, and in
appreciable doses. A poultice, saturated with the tincture or distilled
extract, may be applied externally, in addition to its internal use.
Absolute rest to the heart should be enjoined, the danger of heart fail-
ure being greater than in endo- or pericarditis. The extremities should
be kept warm. The patient must be kept in the recumbent position
all the time, not rising for urination, defecation, or any other purpose.
The condition most to be dreaded is heart failure, even from the
beginning. In some cases, during the first stage, Aconite or Verat. alb.
may be indicated, but should be used carefully, in an attenuation not
lower than the 3. In those cases in which the dyspnea is most dis-
tressing, and the pulse weak, irregular, and collapsing, Convallaria will
prove a valuable remedy, in doses of 3 to 5 drops of the 1' dilution,
frequently repeated.
We cannot hope to cure a general carditis; only those cases in which
the disease is circumscribed are supposed to recover.
Diffusible stimulants should be used in order to keep the blood
from accumulating in the heart, thus increasing the danger of heart
failure. Of all such stimulants, I know of none equal to Aromatic
spirits of Ammonia, given in syrup or glycerine, in doses of 10 to 15
drops every hour, or oftener. Alcohol is the worst of all so-called
DISEASES OF THE ORGANS OF CIRCULATION.
425
stimulants in such cases, for it paralyzes the vaso-motor system and
favors the tendency to cardiac congestion. Equally dangerous is
Quinine, for it rivals Alcohol as a vaso-motor paralyzer.
Should a partial recovery take place and the heart be left in a
paretic state, with probable tendency to fibroid tissue-degeneration,
Hydrastis, Arsenite of Antimony, Ferrum, and Iodoform would be
indicated.
ATROPHY OF THE HEART.
BY E. M. HALE, M.D.
Definition. The old writers called this "phthisis," but true, or
simple, atrophy means a reduction not only in size, but in actual weight
of the heart, or a reduction of one cavity in relation to the organ as a
whole.
Sometimes it occurs that the heart-walls are thinned, and hence the
weight as a whole diminished, causing a species of dilatation; the
existence of such a condition has been denied by some authorities;
nevertheless, dilatation is the principal feature, and this condition
'should be considered under that head, if at all.
Varieties.-Chomel (Reynolds) recognizes two kinds, congenital
and accidental.
A heart unusually small from birth is generally well marked, often
appearing with no other characteristic of disease. Hereditary cause.
has not been traced. Women are the more common subjects. Though
persons having an abnormally small heart may be otherwise well
formed, it is in a majority of cases associated with conditions signify.
ing a general arrest of development, especially at the age of puberty, and
particularly a concomitant lack of development in the sexual organs.
Accidental, or acquired, atrophy may result from local or general
causes, the prominent among the latter being chronic wasting dis-
eases, such as phthisis, cancer, marasmus, syphilis, etc.
With reference to phthisis, in 171 cases at the Brompton Hospital,
Dr. Quain found that the heart was below the average in 54.4 per cent.
In typhoid and febrile diseases, protracted in their course, and leading
to great tissue waste, atrophy of the heart may result, but there is no
evidence of direct connection between these diseases and cardiac atro-
phy; the waste is merely common with that of the rest of the body,
owing to a lack of sufficient nutrition.
Partial atrophy is referable to insufficient blood supply from vascu-
lar disease or local blood pressure, or to fatty infiltration.
The local causes of atrophy are those which influence directly the
local nutrition, such as pressure upon the heart by pericardial adhe-
sions, tumors in that region, crowding the heart into unfavorable po-
sitions, compression by fatty tissue, and other like causes.
The same
426
A SYSTEM OF MEDICINE.
condition results by interference with the circulation in the coronary
arteries, from causes similar to those just named, or from malforma-
tions, or from diseases of the vessels themselves.
Pathology. In simple atrophy the heart presents a general and
uniform diminution in weight and size, as regards both its walls and
cavities. In local atrophy some one cavity is proportionately smaller
than the others. Care, however, should be taken to get the actual
size and weight of the heart, not depending upon its apparent condi-
tion post-mortem, for the ventricles may have stopped in systole, and
the blood have been expelled, thus presenting a deceptive smallness.
In color, the heart may be normal or pale, sometimes of a brownish
tinge. The pericardium may look "like a withered apple " (Laennec),
while the coronary arteries may be tortuous and prominent. The
walls are tough and firm, if the atrophy is not due to the presence of
fat; microscopically, the primitive bundles are seen to be lessened in
size; the fibres are fattily degenerated. Pigment of a reddish-brown
tint may also be noticed.
Symptoms.-The symptoms and signs of atrophy of the heart
are those which might be expected to result from diminished size and
power of that organ. The characteristic phenomena are those of
feeble circulation; the physical signs are chiefly diminished area of
præcordial dulness, a feeble impulse, the apex-beat being above and
within the usual situation; diminished area of audible sounds, and a
small, weak pulse.
Diagnosis. The diagnosis is difficult during life; chief reliance
should be placed on general weakness with diminished area of dulness,
after care has been taken to eliminate from causes of weakness any
other marked conditions, and when there is associated with it some
one of the causal signs already given.
Prognosis. The prognosis is unfavorable, as little can be done to
remedy the condition; it depends, however, greatly upon the disease.
to which the atrophy is secondary.
Treatment. If it were possible, in the present state of our knowl-
edge, to accurately diagnose atrophy of the heart, and its causation,
we might treat it with some degree of success. For example: if it be
really congenital, and found to exist in childhood, the diet and hygiene
could be so regulated as to favor the increase in the size of the heart by
increasing its nutrition. Then, by the use of such medicines as Ferrum
phos., Digitalis, Aurum, Iodum, Iodoform, Cod-liver oil, and Oleum Sabal ser-
rulata, the heart might be stimulated to increased action and nutrition.
In those cases referred to by Parrot, which are due to a simultaneous
arrest of the growth of the heart and of the sexual organs at puberty,
similar hygienic means could be adopted. Besides a more nutritious
diet, general massage and electricity applied to the ovaries and uterus
would tend to assist in the sexual development. Early marriage would
•
:
DISEASES OF THE ORGANS OF CIRCULATION.
427
tend to the same result; so would a residence in Colorado and Cali-
fornia, where the air is pure, rich in oxygen, and of such rarity as
would stimulate the cardiac action. Certain medicines lead to the
same results, namely, Calcarea phos., Ferrum phos., Aurum, Phosphorus,
Cannabis ind., Iodum, and the two nutritive oils above mentioned.
When cardiac atrophy is the result of, or the concomitant of, wasting
the
diseases, such as phthisis, syphilis, chronic suppuration, diabetes, etc.,
remedies should be directed to the cause, and its removal brought
about, if possible.
Narrowing of the coronary arteries, if structural, can not be removed
by medicines. It is possible that a narrowing might be caused by
spastic contraction, due to some abnormal condition of the vaso-motor
system. If we knew this to be the case, some good results might be
brought about by the careful use of China, Quinia, Alcohol, Glonoine,
Nitrite of Amyl, pushed to the extent of normal dilatation of the cor-
onary arterioles. If the atrophy were caused by compression from
pericardial effusion, remedies which would remove the deposit or exu-
dation, namely, Iodide of Potassa, Iodide of Baryta, Iodoform, and
Sulphur, should be prescribed.
If from pericardial adhesions, we can only hope to prevent atrophy
by a treatment tending to increase the power of the heart, thus assist-
ing it to overcome the obstruction to its free action.
The above recommendations are only suggestive, and must be, to a
great extent, theoretical; but even such treatment, judiciously followed,
often results favorably in many diseases.
Until we know that atrophy of the heart has been caused by drugs,
we cannot adopt any specific homeopathic treatment.
HYPERTROPHY AND DILATATION.
BY E. M. HALE, M.D.
Enlargement of the heart is a term which embraces abnormal in-
crease of that organ, as regards either volume or weight, or, as is com-
monly the case, increase in both volume and weight.
Increase in the weight of the heart and increase in volume are dif-
ferent forms of enlargement, either of which, although they are
usually associated, may exist independently of the other. The heart
may exceed the limits of health as regards weight, from an increased
thickness of its walls, the normal volume being retained.
This is a condition sometimes found after death, although in the vast
majority of cases in which the weight is augmented, the volume ex-
ceeds the healthy limit.
On the other hand, the volume of the heart may be abnormally
great, the cavities being enlarged, while the thickness of the walls is
428
A SYSTEM OF MEDICINE.
so far diminished that the normal weight is retained. The latter form
of enlargement is also a very rare occurrence, the organ generally in-
creasing in weight when its volume is greater than in health. Abnor-
mal increase of the heart in weight, due to morbid thickness of the
muscular walls of the organ, constitutes the morbid condition called Hy-
pertrophy. Abnormal increase of the heart in volume, due to unnatural
size of its cavities, constitutes the morbid condition called Dilatation.
These names, hypertrophy and dilatation, thus denote different forms
of enlargement of the heart which exist sometimes separately, but
usually together.
A well recognizable classification has been adopted by most writers,
to be used when the condition of hypertrophy is most prominent; this
classification is set down below. In order to make the subject clear,
we will consider the two general conditions under separate headings.
HYPERTROPHY.
Synonyms.-French, Hypertrophie du Coeur; German, Hyper-
trophie des Herzens; Active aneurism of the heart (Corvisart), Uni-
form enlargement of the heart, distinguished from dilatation (Burns);
Hypersarcosis cordis (Lallemand).
Definition. In a general sense, hypertrophy means an increase in
the size and weight of the organ, "due to an excessive development
of some one of the constituent elements of its walls;" but in an exact
sense, it is an over-growth of the muscular tissue only. An increase
in connective tissue substance or in the fatty tissue is spoken of as
"false hypertrophy," and an abnormal increase in either the endo- or
peri-cardium is more properly referred to under those heads.
Varieties. The classification mentioned above is as follows:
I. Hypertrophy exists, in some cases, without any alteration of the
cavities, the latter remaining normal. This has been called pure or
"simple hypertrophy."
II. The cavities are sometimes found to be diminished in size below
the limits of health. This has generally been admitted as a variety
of hypertrophy, although its existence, as a morbid condition, has been
questioned. It has been distinguished as concentric hypertrophy, or
hypertrophy with contraction. "Cruveilhier and Budd pointed out
that the condition called concentric hypertrophy is the result, not of
hypertrophy, but of a powerful contraction of the organ, suddenly ar-
rested, as it were, by death." "Rokitansky acknowledges the rarity of
the concentric hypertrophy, yet thinks it does sometimes occur; it is
said to have been found in the right ventricle in some cases of con-
genital malformations" (Quain).
III. The variety occurring much more frequently than the others is
characterized by the coëxistence of dilatation to a greater or less extent;
this is called eccentric hypertrophy, or hypertrophy with dilatation.
DISEASES OF THE ORGANS OF CIRCULATION.
429
"Hypertrophy may affect only one compartment of the heart, or more
than one, but the organ is seldom enlarged throughout. The ventri-
cles are much more frequently hypertrophied than the auricles; the
left ventricle more frequently than the right,—but the right auricle
more frequently than the left, for the left auricle shows the change
very seldom.
These subdivisions, although based on distinctions which are valid,
are yet more or less embarrassing, but they are consistent with the
different morbid conditions of the heart as determined by examina-
tions after death, although not accompanied by any marked diagnostic
criteria by means of which they may be positively discriminated at
the bedside during life.
In cases of hypertrophy the cavities may, or may not, exceed their
normal capacity; if the hypertrophy be neither simple nor concen-
tric, it should be studied as hypertrophy with dilatation whenever the
former predominates over the latter. The symptoms and signs enable
the diagnostician to determine, often with positiveness, the existence of
hypertrophy, which may be either simple or predominant over a co-
existing dilatation; but to discriminate between the cases in which the
hypertrophy is simple and those in which it predominates over a co-
existing dilatation, is a problem in diagnosis by no means easily
solved.
Ætiology. Generally, if not invariably, enlargement by hyper-
trophy, which is now taken to mean over-nutrition, hyperplasia, in-
crease in the muscular substance of the heart, is the result of pro-
longed abnormal force of the heart's action. It is difficult to account
for this form of enlargement, except as caused by augmented muscular
power for a long period; and generally there are obvious reasons present
to account for this enlargement. The mechanism is the same as in the
familar examples of certain voluntary muscles becoming dispropor-
tionately developed when inordinately exercised. The muscles of the
arm of the blacksmith are strikingly in contrast with the muscles of
the lower limbs; and the reverse is true of pedestrians and dancers.
Involuntary muscles, aside from the heart, also present examples.
For instance, the muscular substance of the urinary bladder may
become enormously hypertrophied when the power of contraction of
this organ has been for a long time increased in consequence of ob-
struction to the expulsion of the urine.
Clinical observations show that in most cases of enlargement of the
heart by hypertrophy, there are prior morbid conditions which stand
to it in a causative relation, and hence, it cannot be too strongly in-
sisted upon that hypertrophy is almost perfect compensation; but
when dilatation is coëxistent, the condition passes into the more gen-
eral class, and we must seek the cause in some abnormal (morbid)
circumstance; it may be impossible to separate hypertrophy and di-
430
A SYSTEM OF MEDICINE.
latation in their causation; in fact, it is probable that dilatation gen-
erly precedes hypertrophy (Fothergill).
In strict language, hypertrophy cannot be said to have any predis-
posing causes, for it is a healthy reaction against a morbid influence;
so we look for exciting causes, adapting Dr. Quain's classification.
(Lumleian Lectures, 1872.)
The three divisions are I. Nervous; II. Physical; and III. Nutritive.
Nervous causes are, of course, such emotional conditions as produce
palpitation and heart disturbances: excitement, anger, the various
passions, or stimulants, as coffee, tea, coca, tobacco, alcohol.
Physical causes are overwork, undue exertion, irregular calls upon
the heart for enormous blood supply, especially in strained or cramped
positions, impediment to the action of the heart or to the circulation
of the blood and valvular lesions, pericardial effusions, diseases of the
blood vessels, as atheroma, and by displacements, deformities of the
spinal column; hypertrophy may result from chronic Bright's dis-
ease, or from an aneurism which offers resistance to the flow of blood 1 ;
or from diseases of the lungs, causing hypertrophy of the right
heart. It follows, naturally, upon dilatation, in a compensatory effort;
hence, plethora may induce hypertrophy; pregnancy, also, though
generally the heart, like the womb, becomes normal by involution.
The changes occurring during puberty may cause temporary enlarge-
ment.
Any nutritive advantages may cause hypertrophy, taking into ac-
count the local nutrition and the condition of the blood; rich food
(nitrogenous), iron, etc., favor development in muscular structure, and
as this increases, the coronary arteries enlarge, so that the heart has
increased blood supply.
Directing careful attention to the mode in which valvular obstruc-
tions give rise to hypertrophy we shall be led to consider the develop-
ment of the affection in the different anatomical divisions of the heart,
respectively, taking them up in the order of their greater relative lia-
bility to enlargement.
The left ventricle is oftenest enlarged, caused by stenosis of the aor-
tic valves, for the opening is both narrowed and stiffened, thus de-
manding an increase of force which leads to hypertrophy. To this
may be compared the loss of elasticity and the roughening of the
inner coat consequent upon old age. Aortic regurgitation often in-
duces great enlargement; indeed, it is in this condition that the heart
becomes so wonderfully enlarged as to merit the name of cor bovinum
(one heart weighed 40 oz.). Aortic aneurism (as mentioned) may lead
to hypertrophy.
Next in liability to enlargement is the left auricle-from the causes
produced by mitral insufficiency. A regurgitation of blood at each
ventricular systole distends the auricle again, which has thus to do
DISEASES OF THE ORGANS OF CIRCULATION.
431
double work, and hence, naturally enlarges; this results not only in
hypertrophy of the left auricle, but also in engorgement of the lungs
and hypertrophy and dilatation of the right heart.
Next comes the right ventricle, which may become both dilated and
hypertrophied in any primary lesion, causing pulmonary obstruction,
but especially when the origin can be traced to the left heart. In
emphysema, fibrosis, and consolidated lung, the impediment to the
circulation induces hypertrophy of the right ventricle; this condition.
may reflect upon the right auricle; but though disease of the pul-
monary orifice and tricuspid stenosis are both rare, yet tricuspid re-
gurgitation is not unfrequently the result of right ventricular hyper-
trophy," and this, in its turn, causes dilatation-generally with hyper-
trophy of the right auricle. General systemic venous obstruction
follows; and Hope says that venous retardation may work backwards
through the capillaries to the minute arteries, the consequent increased
resistance in which may induce left heart hypertrophy."
(C
Pathological Anatomy.-True hypertrophy implies the enlarge-
ment of the heart-walls, due only to increase in the amount of the
normal muscular fibres; according as this increase is manifest, is the
hypertrophy noticeable. There is no growth of new tissue different.
from the normal heart muscle. Some histologists claim that the indi-
vidual fibres are enlarged, but it has never been accurately demon-
strated. There may be (the so-called false hypertrophy) an increase
of the connective tissue element between the muscular fibres, but this,
when excessive, instead of strengthening the heart's action, may weaken
it. In this form, the color is lighter than the normal red, a gray
hue." A true hypertrophied heart is somewhat darker and redder
than the normal organ, and is firm in its consistency. There may be
hypertrophy of only the wall of but one compartment, the other walls.
being abnormally thin. In examining a heart, care should be taken to
see whether the organ as a whole is enlarged, owing to mere dilatation,
or whether there is actual thickening of the walls themselves. Simple
hypertrophy usually precedes, to a small extent, that condition with
dilatation. The left heart is more often affected, as has been stated,
and the ventricle particularly, from the normal thickness, six or seven
lines, to one or one and a half inches. The parietes are more apt to
enlarge than the divisions between the cavities. The right ventricle
is generally thickest at its base, and runs from normal (two and a half
lines) to an inch. The columnæ carneæ of the right ventricle are par-
ticularly apt to enlarge, but when dilatation occurs they stretch and
grow thin. "The substance of an hypertrophied left ventricle can
generally be torn with ease, while that of an hypertrophied right ven-
tricle is tough and leathery." Twice the natural thickness is the ex-
treme for auricular hypertrophy, and the auricles are usually dilated.
In marked hypertrophy, the organ is generally tilted up, as to its apex,
432
A SYSTEM OF MEDICINE.
1
it becomes more globular, and there is a change in form. The coro-
nary arteries are enlarged.
Symptomatology.-The special physical signs of cardiac hyper-
trophy are, by all means, the most important, but these will be dis-
cussed under the head of diagnosis; it should consequently be remem-
bered that hypertrophy of the simple kind is quite apt to exist and
the patient remain quite ignorant of it until some acute disturbance
brings it on, and I do not much doubt but that some hypertrophic
changes are normal in advancing old age. General symptoms are most
frequently mingled with, and confused by, those of concomitant, cardiac,
or other, symptoms, and pure idiopathic hypertrophy of an exaggerated
type is rare. The only rational symptoms, therefore, are those indi-
cating increased force in the heart's action. Among these may be
grouped the undue rush of blood to various parts. When to the head,
we have cephalalgia, flushing of the face, throbbing epistaxis, vertigo,
etc.-referable especially to the left ventricle; when the rush of blood
falls upon the lungs, it causes dyspnoea, cough, hæmoptysis, and de-
notes pulmonary engorgement, due to hypertrophy of the right ven-
tricle.
In cases in which the pulmonary obstruction is sufficiently great,
the blockade may be referred to the systemic system, influencing the
liver and the portal circulation-these rarer symptoms being caused
by right heart enlargement.
"Of the powerful action of the heart, the patient would be conscious
when his attention was directed to it, and it would be apparent from
the movement of parts of the body and the dress. In general, the
digestive and assimilative functions would not be expected to offer any
marked symptoms of disorder; the muscular strength would not be
impaired, nor the functions of secretion or excretion interrupted "
(Flint).
Palpitation is a common symptom in all organic disease of the heart,
and is often very marked in cardiac enlargement; bodily or mental
excitement may bring this on, in cases of hypertrophy with dilatation
especially, apart from other functional disturbances; and this grows
alarming when dilatation is marked. Hypertrophy gives a pulse
strong, full, and tense, less compressible than normal, and dwelling.
under the finger, due to the increased force in the ventricle which con-
tracts stronger and requires more time for it. (The reader should
refer to the chapter on Physical Diagnosis to distinguish between the
pulse in ventricular hypertrophy, and that in mitral stenosis and in-
sufficiency, in aortic regurgitation, and other affections of the valves.)
The eyes may be bright, shining or bloodshot, owing to increased
general pressure.
Diagnosis.—The few systematic symptoms given should always be
taken into account in making a diagnosis of hypertrophy, but special
DISEASES OF THE ORGANS OF CIRCULATION.
433
attention should be paid to the physical signs of enlargement of the
heart, elicited by examination. Dr. Flint, in his Diseases of the Heart,
gives the following excellent summary:
1. Percussion. "The area of the superficial cardiac region is ex-
tended beyond the range of healthy variation. The degree of dulness
within this area is greater than in health, and the sense of resistance
more marked. The limit of the deep cardiac region-in other words,
the boundaries of the heart-are generally defined by careful percus-
sion; the dimensions of the space which the heart occupies being thus.
ascertained with precision, and the form of the organ delineated on
the chest. Enlargement of the right or left ventricle is sometimes
determined by the extent of the area of dulness at the base of the
heart, on the right or left side of the sternum." [When this area of
increased dulness is increased, especially towards the left, sometimes
as far downwards as the eighth rib, and as far towards the right as
within an inch of the axillary line, we may presume there is hyper-
trophy of the left ventricle. When dulness is towards the right, the
right ventricle is affected, and when dulness extends upwards, we may
infer that there exists trouble in the auricles.]
2. Palpation. “The apex of the heart is moved to the left of its
normal position, and is lowered, the extent of variation, in either
respect, being proportionate to the degree of enlargement, provided
extrinsic causes may be excluded. The area within which the apex-
beat is felt is extended beyond the range of health. Abnormal im-
pulses are felt in two, three, or more, intercostal spaces, the additional
impulses either synchronous or alternating with the apex-beat, in
some instances referable to the auricles, although due to the ventricular
systole; and, when felt in the epigastrium, due to the action of the
right ventricle." [When the apex-beat is very forcible, and extending
downwards, the left ventricle may be suspected.]
3. Auscultation.—" The respiratory murmur is not appreciable within
the superficial cardiac region in tranquil breathing, and is sometimes
wanting when the breathing is forced; it is feebler over a larger area
within the præcordia than in health. The boundaries of the heart
are defined by abrupt cessation, or notable diminution of vocal reson-
ance, and the augmented space which the organ occupies, in the way
determinable in corroboration of the evidence afforded by percussion."
[If the impulse is very strong, sufficient to move the head of the aus-
cultator when the stethoscope is applied, described as a slow, heaving
motion, and the systolic sound less clear, and more muffled, as the
muscular sound is excessively pronounced, the left auricle is involved.
If the impulse seems very superficial, it is the right ventricle.]
4. Inspection.—“ Abnormal projection of the præcordial region in
some cases; the projection is considerable, if the enlargement take
place in early life. The movements of impulsion determined, which
VOL. I.-28
434
A SYSTEM OF MEDICINE.
are also ascertained by palpation, movements are sometimes seen
which are not perceptible to the touch, especially movements which
commence by depression with the systole of the ventricles. Alternate
movements of intercostal spaces are often apparent to the eye, which
are imperfectly ascertained by palpation.
5. Mensuration.-" Prominence of the præcordia is greater than the
corresponding portion of the chest on the right side; in some cases it
is apparent on inspection, but is determined with precision by diamet-
rical measurements. Mensuration is also employed in determining
with accuracy the dimensions of the superficial and deep cardiac re-
gions, the position of the apex-beat relatively to the nipple, median
line, etc."
Physical Signs Distinctive of Hypertrophy.-1. Palpation.-
Abnormal force of apex-beat, denoting not merely excited action of the
heart, but augmented power of the systole, the impulsion being pro-
longed and strong. A strong impulse in the epigastrium in cases of
hypertrophy of the right ventricle; the impulsions are sometimes
communicated to the lower part of the sternum, and extending more
or less over the site of the liver. A strong heaving movement of the
præcordia, in distinction from the shock, more or less violent, due
merely to augmented functional activity of the ventricles.
2. Auscultation.-Increased intensity of the aortic second sound, and
especially of the element of impulsion of the first sound, in hyper-
trophy of the left ventricle, rendering the first sound dull and pro-
longed as well as abnormally intense; exaggerated intensity of the
pulmonary second sound, in hypertrophy of the right ventricle, espe-
cially if associated with obstruction to the pulmonary circulation.
Augmentation of the tricuspid valvular element of the first sound in
some cases of hypertrophy of the right ventricle.
Dilatation may be distinguished from hypertrophy by the evidences
of feeble circulation; by irregularity and intermittency of the heart's
action; and by the feebleness and diffuseness of the apex-beat.
In establishing a diagnosis of hypertrophy, care should be taken to
eliminate all signs of pleuritic or pneumonic affection, which might
mask or similate these signs of the heart.
Complications and Prognosis.-As simple hypertrophy is a
compensatory process, it may go on for a long time unnoticed, and no
other form of disease may arise from it; but when dilatation is added,
the usual symptoms of palpitation, dyspnea, congestion of veins, and
disease of arteries, etc., may result. Cerebral hemorrhage is not in-
frequent, as in Bright's disease. Acute febrile diseases seem to take
hold easier when hypertrophy is present; the kidneys may suffer, and,
as a natural consequence of increased action, there may be serous
effusions into the cavities and subcutaneous areolar tissue.
Simple hypertrophy, if the cause be removed in time, is not dan-
DISEASES OF THE ORGANS OF CIRCULATION.
435
gerous, and long life need not be interfered with. When other com-
plications are set up, as valvular or pulmonic lesions, the case grows
more serious; but when this hypertrophy is itself secondary to de-
generation of arterial coats, when dilatation is advancing, and espe-
cially in Bright's disease, the prognosis is extremely unfavorable.
Treatment.-The treatment of this condition of the heart has
already been discussed in the article on Valvular Diseases, where the
subject of unequal, or of excess of, compensation was mentioned. But
for the sake of completeness, some general indications will be given.
The following considerations, relating to the object of treatment, are
so well given by Dr. Gowers, in Reynolds's System of Medicine, that no
apology is necessary for quoting them entire :
"The judicious management of hypertrophy depends on the recog-
nition of the fact that it is sometimes purely beneficial, usually wel-
come as a substitute for its too frequent associate, dilatation, and rarely
directly prejudicial. No universal rule for the treatment of hyper-
trophy can, therefore, be laid down, since the proper course may be
sometimes to foster its occurrence, sometimes to lessen its excess, or,
failing that, to prevent its increase.
(C
Hypertrophy of the heart being the result of two factors, nutritive
activity and increased work, its increase may be, to some extent, pre-
vented, and its amount diminished, by lessening each factor in its
production. The nutritive activity of the heart can be lessened only
by diminishing that of the general system by low diet, bleeding, etc.
But to attempt this while the causes of hypertrophy continue, is to
substitute dilatation for hypertrophy. The system has been advocated,
however, in conjunction with causal treatment, from the time of Bertin.
It may be questioned whether the causes of established hypertrophy
can ever be sufficiently reduced to permit the safe employment of
'antiphlogistic' measures. Moreover, they can rarely be necessary.
We see in the voluntary muscles that reduction of work is invariably
followed by reduction in size of muscle. Every analogy suggests that
cardiac hypertrophy will rapidly subside when the condition which
excited it has lessened or ceased. It is not often that this result can
be proved to occur in the case of the heart, but instances are not in-
frequent in which it seems to take place. The reduction of the causes
of hypertrophy, i. e., the working of the heart, to a minimum, consti-
tutes, then, the main object in the treatment of hypertrophy. This
work is partly of a constant, partly of an occasional, nature. The
normal work of the circulation must be carried on; the permanent
organic cause of the hypertrophy can rarely be lessened; but the occa-
sional addition to the heart's work involved in violent muscular exer-
cise, increased frequency of contraction from alcohol or emotion, in-
creased obstruction from remediable states of blood or local inflam-
mations, may all be to a large extent removed. Rest of body and
436
A SYSTEM OF MEDICINE.
mind is, therefore, the first and most essential element in treatment.
All exercises which quicken the pulse must be absolutely forbidden.
Emotional tranquillity must be as far as possible secured. The utmost
temperance in food and alcohol should be enforced. A fair amount
of nitrogenous food, and a very little light wine with it, constitute the
best diet. If food is well taken without alcohol, the latter may often,
with advantage, be prohibited. The digestive organs should be care-
fully attended to. Nothing disturbs the action of the heart so readily
as a distended stomach. Food must be moderate in amount, and
every cause of transient plethora removed. The secretions must be
carefully regulated, and impaired action of the kidneys or the skin
must be supplemented by mild purgation or diuresis. Local inflam-
mations, bronchitis, etc., must be carefully guarded against, and, when
they occur, removed as speedily as possible.
"Too often, however, the amount of obstruction which can by these
means be removed bears but a small proportion to the total against.
which the heart has to contend. Can this permanent obstruction be
further reduced? To some extent the work of the heart can always be
lessened by reduction in the total quantity of the blood. This formed
an important element in the old system of treatment, and it was partly
with this object that frequent and repeated bleedings were recom-
mended. Their condemnation in the present day is superfluous. It
may be doubted whether occasional leeching, which still finds advo-
cates, is justified by its ultimate results, although its immediate effect
is to give relief to the heart. Restriction of fluids has been suggested.
It is, at any late, a harmless measure; but the rapidity with which
urinary secretion regulates the volume and density of the blood ren-
ders it doubtful whether more than a very transient effect is pro-
duced.
rare.
"It will be gathered from these statements that the conditions under
which an attempt at the removal of hypertrophy is indicated are very
Whenever the hypertrophy can act immediately on the causal
resistance, its influence is always, on the whole, and sometimes en-
tirely, beneficial. Only when the over-action of the heart is primary,
or is due to a cause which has ceased to operate, is it to be attacked
directly. In the rare instances in which violent exercise has called
out persistent hypertrophy, or some obstruction has been removed, the
condition may call for immediate treatment to reduce its effect. Where
the obstruction is situated far from the heart, and degenerated vessels
are interposed which have to bear the full force of an over-acting ven-
tricle, as in Bright's disease, the question also sometimes arises of the
chances of evil from vascular rupture, on the one hand, and from a
weakened heart on the other. The certain, slow, but sure evil of a
weakened heart will generally counterbalance the possible catastrophe,
and any attempt to lessen the cardiac strength will be avoided."
DISEASES OF THE ORGANS OF CIRCULATION.
437
From these considerations and reflections it will be seen that the
treatment may be divided into Hygienic and Medicinal.
1. Hygienic.-The hypertrophied heart is already doing too much.
work; it does not sleep enough; in other words, its periods of rest are
not enough to balance its periods of labor. The first hygienic indica-
tion therefore is to lessen its action without decreasing notably its
strength, at least not until the causes of the hypertrophy have been
removed. A person possessing an abnormally hypertrophied heart,
i. e., too large a heart for the work to be done, should adopt a quiet
life, almost as quiet as if he had dilatation, for in the former condition.
all active exercise, especially sudden, severe exercise, surely increases.
the enlargement and the increase of the number and power of the
muscular fibres. All athletic sports are to be forbidden and all ex-
citing emotions avoided. The more quiet the heart is kept, the more
is hypertrophy held in check.
The nutrition of the heart must be curtailed, and all foods which
rapidly make blood and muscular tissue avoided. Meats, alcohol, coffee,
leguminous foods, carbonaceous and fatty foods must be prohibited.
A cooling and non-stimulating diet of cereals, vegetables, rice, soups,
fruits, milk, bread, etc., should constitute the aliment of the patient.
Climate should be considered. High altitudes, where the air is light
and the atmospheric pressure is small, should be selected. The high
region of Colorado, the Rocky Mountains, and certain portions of Cali-
fornia, are most favorable to patients with hypertrophy. The prairie
regions of the Western States, the low valleys of the Eastern, Middle
and Southern States, especially when malarious, are badly suited to
such cases. The heart works easiest where the atmospheric pressure
is smallest. Sea air is not, as a rule, beneficial to cases of hypertrophy.
In such climates, patients with hypertrophied hearts are more liable to
cerebral congestion, with apoplexy and epistaxis; to pulmonary con-
gestions, with hemorrhages; to hepatic congestions with bilious at-
tacks, jaundice, etc.
2. The medicinal treatment must be cautious and conservative. We
must avoid reducing the force of the heart, as well as increasing its
power and the blood-pressure. Even the allopathic school have aban-
doned the blood-letting so much in vogue previous to twenty years
ago. Bleeding will give temporary relief, but increases constantly
renewed necessity for the bleeding, and finally weakens the heart
beyond recuperation. Homoeopaths, as well as allopaths, should be
cautious in the use of Aconite, Gelsemium and Veratrum viride.
Judiciously used, they will give relief, not only temporary but perma-
nent.
Aconite is best indicated in concentric hypertrophy when the area of dulness is
not large; the beats of the heart are short, hard, forcible, showing great power, but
small amplitude of contraction; the pulse is small, hard and incompressible. The
438
A SYSTEM OF MEDICINE.
mind is anxious, and there is great restlessness of body and mind. The attenuations
from the 1* to 6* should be selected, according to the age, sex and other conditions.
Gelsemium.—This remedy I have rarely found useful in true hypertrophy.
In a few cases it has acted admirably where the capillary system was congested.
Veratrum viride is doubtless our most potent, as well as our safest, remedy
when the force of the heart is enormous and the blood-pressure becomes dangerous.
The area of dulness shows the muscular tissue of the heart to be greatly increased; the
contractions are powerful, the beats large, heaving, and the pulse bounding and hard,
rapid or slow. In such cases there is danger of cerebral or pulmonary apoplexy and
hæmorrhage. The dose in such cases may safely range from one to five drops of the
tincture to the same quantity of the 1' dilution, repeated every hour or two, and stopped
as soon as the pulse becomes softer. If the arteries are atheromatous, larger doses are
required than when the arterial coats are elastic. I have never seen bad results from
such doses when properly watched, while the beneficial effects are always soon ob-
served.
Cactus grandiflora and Cereus Bonplandii are next in value to
Veratrum viride. They are indicated for nearly the same physical symptoms, but the
first has one characteristic symptom which always calls for it, namely: the "sensation
as of an iron band constricting the heart." The 1 to 3 dilution will be found most
appropriate.
Kalmia has many symptoms common to all the above, and in certain cases will
be found palliative.
Aurum, 6th, has been found useful by Klapka.
Glonoine is exquisitely homoeopathic to the violent action of the heart, with in-
tense cerebral congestions; great blood-pressure in the inner and outer arteries of the
head, with throbbing, pressing, bursting pains, but should never be given lower than
the 3 dilution. Its close analogue, Amyl nitrite, might be tried in the same dilutions.
The "cardiac tonics," Digitalis, Convallaria, Adonis, Squill, Asparagus, Nux vomica and
Coca are primarily homoeopathic to hypertrophy with abnormal strength of the heart;
but, as asserted by me in another place, I have never been satisfied with their action
in such conditions, in minute doses. If prescribed at all, the dose should not exceed
in quantity the 3d or 6th dilution. I make exception in the case of Coca. In cases
where the enlarged and powerful heart has been excited by emotions or undue active
exercise, a few doses, sometimes a single dose, of 15 drops of the tincture often give
quick relief. In this respect it resembles Coffea, which in the 3' dilution will often
gain equally pleasant results.
Having considered the treatment of pure hypertrophy, we will pro-
ceed to the
Treatment of Hypertrophy with Dilatation.-This condi-
tion of the heart may be said to begin as soon as normal hypertrophy
ceases. Dr. Fothergill, in his chart showing the nature of the changes
in hypertrophy (page 79), gives the following diagnostic differences :
Pure Hypertrophy.-"No irregularity, palpitation occurring only when
hypertrophy is still insufficient. No loss of power and no subjective
symptoms. Pulse strong and incompressible. No loss of rhythm in
pulse or heart beats."
Hypertrophy with Dilatation.—“ Palpitation easily induced. Often a
halt in rhythm at distinct intervals, increased in frequency by exer-
tion. Power limited. Subjective symptoms more or less marked.
Pulse rather full than strong, and compressible."
Fothergill claims that hypertrophy needs no treatment, because it is
a purely compensative process. He would not interfere even if apo-
plexy threatens. So far as he refers to the treatment of his school, his
assertion is proper enough, for the medicines he would use would in-
jure the heart's integrity rather than preserve it. He makes one curious
DISEASES OF THE ORGANS OF CIRCULATION.
439
exception. He would use Digitalis in small doses, when there was
"excessive but irregular action." A homoeopathic procedure which
he is not honest enough to admit.
He admits, however, that during the continuance of hypertrophy
we should watch carefully for the slighest sign of a failing heart. The
first sign, he says, is always palpitation. So impressed is he with the
importance of this sign that he says, "It must be borne in mind that
in hypertrophy of the heart, palpitation is always an evidence that the hyper-
trophy is insufficient, not that it is excessive." He does not here allude to
that excessive force which is not palpitation, and of which I have treated
above. I am inclined to believe that in this matter Fothergill is cor-
rect.
If, therefore, we find palpitation to be present in hypertrophy,
we should change our treatment to suit the impending incompetence.
Here the remedies I have mentioned in pure hypertrophy may still be
used, but in smaller doses, for this tendency to failure is a condition
to which they are primarily homeopathic. We shall find that Aconite,
Gelsemium, Veratrum viride, Cactus, Cereus, Veratrum album, and
Arsenic, when given in minute doses (3d to 6th), will give just as good
results as when given in larger doses, in excessive hypertrophy. I
need not enumerate the symptoms indicating their use. It is sufficient
to say that the symptoms are nearly opposite to those which indicate
them in hypertrophy-the two most prominent being palpitation,
with failing force and loss of rhythm. But the remedies upon which we
must rely in the majority of cases of hypertrophy with dilatation, are
those I have already mentioned and classified as "cardiac tonics."
Digitalis, Convallaria, Adonis, Cactus, Prunus virginian., Asparagus,
Squills, Erythrophleum, Nux vomica, Ignatia, Strychnia, will be indicated,
and the dose will lie between the crude drug and the 3d dilution; or
at about the 1. (Strychnia not lower than 2 trituration.)
It must be remembered that as soon as the dilatation is in excess of
the hypertrophy, or as soon as the heart begins to fail, there is always
a danger of structural degeneration, confined, perhaps, at first to single
muscular fibres. Our object is to build up the remaining fibres before
they begin to degenerate. This cannot be done by medicines alone—
however closely they are affiliated. The hygienic surroundings and
habits of the patients must be changed. The diet must be gradually
made more nutritious. Meats, eggs, cream, and pure wine may be
allowed in moderation. And if, notwithstanding this diet, the slight-
est anæmia shows itself, Iron, Copper, Manganese, and other hæmatics
should be given in small doses, not forgetting, however, that Hydrastis,
Helonias, Aletris, Ignatia, Nux vomica, and the mineral acids, all act
sometimes to enrich the blood by increasing the proper digestion and
assimilation of food.
440
A SYSTEM OF MEDICINE.
DILATATION.
The arrangement adopted for the classification of this affection of
the heart is in general one corresponding to that used in treating of
hypertrophy, namely:
Simple dilatation, in which the cavities are enlarged, the walls at
the same time remaining normal.
Active dilatation, in which the cavities are enlarged, while, at the
same time, there is a compensating growth of the walls of the heart,
thus being eccentric hypertrophy, but looked at from another stand-
point.
Passive dilatation, in which the cavities are enlarged at the expense
of the walls, which latter, consequently, are thinned. This is the
usual form. However, it must be remembered that dilatation and
hypertrophy are nearly always connected; it is, indeed, a question
whether one does not necessarily imply the other; but the treatment
is to differ as the hypertrophy or the dilatation predominates. It
must be remembered, also, that hypertrophy is always a compensatory
process, at times functionally normal, as during pregnancy and
puberty, but when we find that even the hypertrophy induced is not
sufficient to compensate for the growing dilatation, and that weakness,
in such cases, not strength, is indicated, we must treat this weakness
manifesting itself in dilatation, and not the hypertrophy. Hence, we
see that in the first class, or in simple dilatation, there is, or undoubt-
edly will be immediately, a compensating hypertrophy. The second
class, active dilatation, we found was the same as eccentric hypertro-
phy, and consequently these two divisions are best studied as mani-
festations of hypertrophy. In the third class, passive dilatation, we
find a condition which means manifestly weakness, a dilatation which
overshadows any compensatory hypertrophy, however much attempt
there may be in this direction on the part of the system,
and conse-
quently this alone needs to be studied under this head.
Etiology.-Dilatation (passive) implies that the yielding heart
walls are not strong enough to resist the pressure from within; if only
a limited portion of the walls be involved, it constitutes an aneurism;
to that condition in which a complete cavity is, or all the cavities are,
involved, the term passive aneurism has been applied.
The dilatation may be due to actually defective heart walls, or to
abnormal blood-pressure, though the walls be in their usually healthy
condition. In the former case, the trouble in the heart wall may be
due to fatty, or other, degeneration, or to textural disease, already at
work, though not visible. In the latter case, the abnormal blood-
pressure may arise from an obstruction to the circulation, which the
heart is unable to meet, or from undue rapidity of action, implying
greater expenditure of force.
Other, we may say mechanical, causes bring 'about this condition;
DISEASES OF THE ORGANS OF CIRCULATION.
441
such as
obstructive disease at the aortic orifice, when resistance is
offered to the free discharge of blood from the left ventricle;" regurgi-
tant disease of the aortic orifice; the effect of continued violent
excitement, either nervous or muscular.
Where there is valve disease, there is apt to be a dilatation also, the
particular cavity affected depending on the particular valve, though
the right ventricle is most likely to manifest weakness, being much
feebler than the left. Hence, it is better to go to the original source of
the lesions, and to study in this connection the effects of valvular dis-
eases. The chief fact to be noticed is that dilatation is a sign of
weakness, and the result of weakness, and should be looked for in
anæmic persons, those displaying impaired constitutions, weakened
by exhaustion of the sympathetic by excessive smoking, by long
debauches, and by neglect of proper hygiene.
The temporary dilatation of acute febrile disease is due to a natural
weakness of the heart's walls.
Pathological Anatomy.-As it is a question whether dilatation
is ever found alone, unassociated with hypertrophy, the examination
can be merely relative, as is the treatment, and the condition of the
patient is to be largely the governing factor.
Should the walls seem unusually thin, the cavities greatly expanded,
the trabeculae wasted, or the orifices enlarged, dilatation may be stated
to have been in excess of any compensating hypertrophy. The auri-
cles should be the chief cavities observed, as they are most prone to
dilate.
Symptoms.-Dilatation means weakness, and this condition is the
radical sign and symptom distinguishing it from hypertrophy alone,
or from hypertrophy with dilatation.
The heart's power is diminished; blood is retained in the pulmo-
nary artery and in the aorta. "The results of dilatation of all the cavi-
ties are that the efferent vessels are in a condition of ischæmia, while
the efferent vessels are abnormally full." (Bartholow.) Cyanosis,
constant hyperæmia of peripheral veins; palpitation of heart; low
temperature; deficiency of arterial blood supply to the brain, and
such concomitant symptoms as vertigo, faintness or syncope, ringing
in the ears, etc. The system is cachectic, nourishment poor, energy
insufficient, elimination defective; all general disorders of the system
may finally be set up. The pulse is irregular, the heart's action feeble;
the pulse may be unequal; the extremities are cold, and lividity may
be noticed.
The symptoms and signs of general dilatation of the heart will be
found to vary within certain limits, according to the stage at which it is
examined. Thus, at an early period of its history, when, however, char-
acteristic features are sufficiently pronounced, the patient will exhibit
languor of body and mind; the extremities, ordinarily of a slightly
442
A SYSTEM OF MEDICINE.
livid tint, will be chilled and benumbed; the pulse, small and regular,
may intermit at long intervals; respiration is normally shallow and
readily quickened by exertion, and the patient is easily put out of
breath by physical effort or mental excitement. There is a constant
hemming or teasing cough, accompanied by scanty serous expectora-
tion and a proclivity to catching cold, which constitutes the patient's
principal infirmity. On these occasions there is great embarrassment
of breathing, which may amount to orthopnoea; the pulse is quick,
feeble, and it may be irregular, the conjunctivæ injected with dark
blood, and the features generally livid and somewhat puffed.
In the ordinary condition of the patient, secretion and excretion are
performed with regularity, although the liver is somewhat engorged
and the patient may be troubled with hæmorrhoids.
The appetite, however, is indifferent, and digestion is slow; and from
time to time, as shown by foul tongue, eructation and anorexia, the
stomach suffers derangement of function, either as a consequence of
some slight indiscretion in regard to food, or in damp and foggy
weather without any such provocation. On such occasions the urine
precipitates a copious sediment of lithates. The extent of præcordial
dulness is horizontally increased, if not masked by emphysematous
lungs. The impulse of the heart is feeble, diffused, and occasionally
intermittent; and a direct point of apex pulsation can rarely be
detected. The præcordial region, viewed in profile, will generally ex-
hibit indistinct fluctuation in one or more intercostal spaces. The
sounds of the heart are sharp and distinct, the first resembling the
second in brevity and pitch, but varying as to clearness and intensity
according to the state of the cardiac walls; it is feeble and low toned,
though well defined, when the walls are fatty or otherwise softened,
but clear and ringing when tissue change does not exist. The pulsa-
tion of the heart is quickened by even the slightest movement of the
body, and on such occasions it is attended with throbbing of the
carotid arteries, and visible fluctuation of the external jugular veins.
When general dilatation has attained its maximum, respiration ist
shallow, labored, and protracted, and usually accompanied by a loud
wheeze; there is complete orthopnoea and impending suffocation
when the patient assumes the recumbent posture even for a moment.
The features, especially the lips, the tip of the nose, and the lobes of
the ears, are livid, the conjunctivæ congested and somewhat jaundiced,
and the eyelids and face generally bloated; surface and breath cold;
the feet cold, puffed, and congested. The pulse is slow, feeble, inter-
mittent, and irregular. Præcordial dulness extended laterally, but
difficult to be defined with accuracy, because the anterior borders of
the lung, which are usually emphysematous, overlie the præcordium
to some extent. The heart pulsates at the ensiform cartilage; its
action is feeble, flapping, irregular, and barely perceptible to the
DISEASES OF THE ORGANS OF CIRCULATION.
443
hand; and if it be not entirely overlain by the edges of the lungs, a
fluctuating movement of its anterior wall is perceptible in one or more
of the intercostal spaces, at the end of expiration. The sounds are
faint, but sharply defined, and high pitched, and if the walls be
thinned but not softened, the first sound closely resembles the second
in rhythm as determined by the cardiac impulse or carotid pulsation.
Fine crepitant rales are audible over the bases of the lungs, which are
somewhat dull, and the chest generally is either non-vibratile or very
feebly so. There is constant teasing cough, accompanied by thin mu-
cous and frothy expectoration, frequently tinged with blood.
Anasarca and serous effusion into the cavities of the chest and abdo-
men quickly supervene, the latter being usually the immediate cause
of death. In such case the mode of death is by coma, resulting from
combined operation of retained renal and pulmonary excreta. An-
other mode of death is, however, not unfrequently exemplified in this
affection, namely, that by thrombosis of the right side of the heart
and pulmonary artery.
The conditions upon which this accident, for as such it may be
regarded, depends are partial stasis of the blood by failure of contrac-
tion in the right chambers of the heart, and by impairment of respira-
tory and nutritive attraction arising from feeble respiration and
arrested tissue-change.
The symptoms which indicate its occurrence are a sense of præcor-
dial oppression, gradually increasing to a point of great intensity, and
attended with tumultuous but feeble action of the heart; great dys-
pnoea and craving for air; restlessness and sighing; the patient starts
from his slumber with great alarm, and is entirely deprived of refresh-
ing sleep; the pulse is quick, weak, irregular, and fluttering, or all but
entirely suppressed at the wrist; the surface is cold, damp, and livid;
respiration is rapid, full, and labored, but manifestly ineffectual,
although air freely enters the lungs, and loud rhonchi or wheezing
sounds are heard all over the chest. The carotid arteries pulsate with
great violence, and the jugular veins are turgid and fluctuating. The
most characteristic symptom of this condition is, however, the besoin
de respirer. The arms are thrown out and extended; the covering is
flung off the chest; the patient begs that fresh air may be admitted,
and declares he is being suffocated, although the chest moves freely and
extensively, and there is abundant circulation of air in the chamber,
and, as judged by auscultatory evidence, in the lungs also. In this con-
dition death usually occurs quite suddenly on the patient's making the
slighest exertion, such as that of sitting up; it is the immediate conse-
quence of the impaction of a mass of fibrin in the tricuspid orifice or
the pulmonary artery, by which the circulation in the lungs is mechan-
ically arrested, the systemic arteries emptied, and the veins gorged
with blood.
444
A SYSTEM OF MEDICINE.
As the physical signs of hypertrophy with dilatation were given,
together with those distinctive of hypertrophy, it is well here to add
those signs which will enable us, in connection with the above symp-
toms, to determine when dilatation exceeds the hypertrophy. I copy
from Flint.
1. "Percussion. The transverse dimensions of the space occupied
by the heart greatly exceeding the vertical, the form of this space
corresponding to the wedge-like or square form of the organ when the
dilatation is excessive.
2. "Palpation. The apex-beat is devoid of abnormal force, and in
some instances suppressed. Absence of heaving movements of ribs
and præcordia.
3. "Auscultation. The element of impulsion of the first sound is
deficient or absent, and the sound is short and valvular, in these
respects resembling the second sound."
Prognosis. "There is no doubt that some degree of dilatation of
the heart, and more especially of the right ventricle, may arise, either
from overexertion or from functional disturbances, and in connection.
with pulmonary disorders; but such dilatation is for the most part tem-
porary or remediable, and only by continuance of its cause becomes
established and a matter of serious importance, but the presence of
dilatation in connection with other diseases becomes grave, and they
or this trouble, may gradually lower the patient's vitality, and thus
hasten his death. Dilatation of the cavities is much more rapid in its
course and important in its results than hypertrophy, but passive
dilatations are more serious than the active form. The heart is weak-
ened, the tissues become diseased, and death may be sudden by rup-
ture or by paralysis, or in attacks similar to angina pectoris.”
General dilatation of the heart is least promising where the organ has
undergone change of structure; it is of unfavorable augury in propor-
tion to the extent and degree of tissue change which the heart has suf-
fered. That of fatty degeneration is the most serious, because the least
amenable to treatment; it is likewise the most liable to terminate in
sudden death by thrombosis or rupture.
That form of affection which is secondary to hypertrophy from val-
vular lesion or from renal diseases is likewise proportionately more
serious than that of primary origin, because of the retrogressive tissue-
change which it implies, and the formidable mechanical resistance
which, in either case, the heart, thus weakened by tissue-decay and by
thinning of its walls, has to overcome in carrying on the circulation.
General dilatation from anæmia or from excessive labor and inade-
quate nutrition is, on the other hand, the most promising form of the
affection, and susceptible not only of improvement, but of cure under
appropriate and persistent treatment. Dilatation from "typhoid soft-
ening" is usually met with in typhus fever or consecutive to it, and is
DISEASES OF THE ORGANS OF CIRCULATION.
445
likewise amenable to treatment. Unless the system can be greatly
strengthened, and dilatation thereby greatly reduced, the hope of re-
covery should not be too strongly encouraged.
Treatment. Although the treatment of dilatation has been in a
manner given in the article on Valvulitis, the lesion is of such impor-
tance that it seems best to go over the ground again, and, perhaps,
more thoroughly.
We will suppose that the physician has had his case in charge for
some time, and has done all he can to remove the causes of the dilata-
tion, or that he sees his case for the first time, and finds dilatation has
obtained to a greater or less extent.
Here it is evident that the main indication is to preserve the integ-
rity of the muscular tissue of the heart from further dilatation, and,
if possible, to build up that tissue and augment the power of the
organ.
Two methods are to be adopted: Hygienic, which includes dietetic and
climatic treatment; and medicinal treatment. Medicines are quite power-
less to bring about restoration, unless the hygienic surroundings are ren-
dered healthful. If the patient is exposed to the influence of malaria
(marsh miasm) or sewer gas, he must be removed out of the reach of
these depressing agents. He should never breathe an air loaded with
"crowd-poison," that terrible poison generated by crowds in unven-
tilated rooms or public halls. He should never breathe in that
deadlier poison carbonic oxide, which generates in unventilated
rooms, or close, filthy streets, or rooms filled with tobacco-smoke.
Tobacco and tea should be absolutely forbidden, for both tend to
paralyze the nerves which supply the innervation of the heart. Coffee
is not as bad, for whatever chemists may tell us of the chemical simi-
larity of Theine and Caffeine, they are almost antagonistic in their
effects on the heart. Cocoa and chocolate are better than tea, if they
are well tolerated by the stomach. The diet should be very nutritious,
but easily digested. Milk, eggs, oysters, fish, and all meats, except.
ham and salt pork and salt fish, may be eaten. Good bacon is not ob-
jectionable. Pastry is prohibited, but simple, plain puddings may be
allowed. A small quantity of good claret, Burgundy, Tokay, or Hun-
garian red wine, diluted with water, and drank with the meals, may
be allowed. If the stomach is weak, the digestive functions unable
to do their work well, thus preventing complete assimilation of food,
the artificial digests, pepsin and pancreatin, should be used. In some
cases I have advised peptonized milk and beef extracts with great
benefit, especially in severe cases. Murdock's Liquid Food will sus-
tain the failing power, even in desperate cases. Beef-tea may be used
as a pure stimulant, not a food, for it is in no sense a food.
The clothing is a matter of vital importance. A weak heart cannot.
keep the body warm. The surface and extremities are cold, and the
446
A SYSTEM OF MEDICINE.
blood which does reach them is carried back to the heart chilled, and
chills the heart. Flannel, wool, or silk and wool underwear should
be worn summer as well as winter, and they should fit the body and
extremities closely, not allowing the cold air to get under them. Hands
and feet, wrists and ankles, should be kept very warm. Ice-water or
cold articles of food should be avoided. In no disease is the homely
axiom that “heat is life, cold is death" more true.
Climate is an important factor. The climate for the weak and di-
lated heart should be dry and warm. It is difficult to get these two
conditions together. But the high lands of California, Colorado, North
and South Carolina in summer, middle Florida and the valleys of
upper Georgia and Tennessee in winter, fulfill these indications. The
climate of Nassau, some parts of Mexico, and Texas, may combine
the two. The lighter the air, the less work the heart has to do.
air rich in oxygen is a tonic to the heart.
An
The emotions have much to do with the condition of the patient.
All such emotions as hope, joy, content, with domestic happiness
strengthen the heart. Grief, sorrow, melancholy, homesickness, and
discontent depress it.
Exercise should be moderate, in the open air, if possible, when
the air and elements are favorable. A too sedentary life tends to
weaken the heart, already weak; while any sudden, powerful, or pro-
longed exertion is not only injurious, but in some cases may lead to
rapid, even sudden, failure of the heart's life.
The medicines to be used in dilatation of the heart may be divi-
ded into four classes.
(1.) Those which are eminently restorative to the wasting of the
heart-muscles. They act by enriching the blood, either by their direct
hematic powers, or by increasing the digestion and assimilation of food,
viz.: Ferrum, Cuprum, Nux vomica, Ignatia, China, Phosphoric acid, Muri-
atic acid, Nitromuriatic acid, Aletris, Helonin, Hydrastis, Lacto-phosphates,
Hypophosphites, Cod-liver oil, and the Chalybeate mineral waters. These,
together with a proper diet, will do much to prevent the dilatation
from progressing, and build up the tissues. The special indications
for their use need not be given here.
(2.) Those which are homœopathic to wasting of the tissues, atro-
phy, etc., namely: Iodine, and its salts; Bromine, and its salts; Phyto-
lacca, Acetic acid, Arsenic, etc.
Iodine, when long continued in large doses, causes wasting of muscular tissues
all over the body, also of the glandular tissues. It is eminently homoeopathic to idio-
pathic dilatation with thinning of the heart walls. It is homoeopathic to the peculiar
impoverishment of the blood which attends some cardiac affections. The Iodide of
potash is sometimes better than Iodine, especially if there is a syphilitic taint in the
blood. Iodide of iron is often better than Iron alone, in dilatation with chlorosis or
anæmia. (The 2 or 3ª trit., or 3 to 5 drops of the syrup, is the proper quantity.)
Arsenic, although primarily increasing the apparent plumpness and appearance of
health, in those who take it for some time in appreciable doses, does not really enrich
DISEASES OF THE ORGANS OF CIRCULATION.
447
the blood, or give good muscular growth, for as soon as its use is stopped, they rapidly
emaciate, the plumpness proves to be anasarca, and the dyspnoea which appears, proves
that the innervation of the heart and lungs has been greatly impaired. It is seconda-
rily homeopathic to paresis and dilatation of the heart, and in small doses is one of
our greatest aids in its restoration. In some cases the Iodide of Arsenic, Arsenite of
Antimony, Arseniate of Gold, or the Arsenite of Strychnia, give better results than the
Arsenic alone.
Phytolacca causes alterations in the nutrition of the system similar to the
Iodides. It has been observed that birds which eat the berries become greatly ema-
ciated. The provings show many points of similarity to Iodine and its salts.
Acetic acid in large quantities has been known to decrease the bodily weight
to the greatest emaciation, attended by muscular wasting, and impoverished state of
the blood. Yet this acid, in small quantities, has been known to remove chlorotic con-
ditions, improve nutrition, in fact, cause a directly opposite condition to its pathoge-
netic effects. It may not be necessary to give it as a medicine (i.e., in dilutions), but we
may allow small quantities with the food.
(3.) The medicines which are primarily homoeopathic to cardiac pare-
sis and deficient innervation are Aconite, Gelsemium, Veratrum album,
Veratrum viride, Helleborus niger, Kalmia, Hydrocyanic acid, Chloral hy-
drate, and Quinine.
We do not know, however, that they are capable of causing, directly,
dilatation of the heart. If they do cause this condition, it is not by any
wasting action on its muscular tissue, but by causing deficient innervation
which leads to it. While I have the fullest belief in the power of this
class to revive the failing nervous energies of a weak heart, I think
they are best indicated as curative agents when no dilatation is present.
In cases when the heart is striving to resist dilatation, and fails to at-
tain the condition of compensation, as in valvular disease, all and each
of these medicines may aid our efforts in preventing dilatation. But
in the condition of actual dilatation I do not believe they will prove
more than palliative, if, indeed, they are of value at all. I am obliged
to say that this opinion is not theoretical, but is based on considerable
experience in the treatment of cardiac diseases. It is not that the law
of similia is deficient, but that these remedies do not cover the totality
of the symptoms, and unless a medicine conform to this rule, it is not
a complete similimum, and consequently not curative.
(4.) This class comprises those medicines which are secondarily
homeopathic to dilatation and weakness; their first effect in massive
doses is hyperstimulation of the muscular and nervous energy of the
heart. Their ultimate primary effect is death of the heart in tetanic
spasm. When not fatal, the reaction from the primary poisoning is a
failure of the innervation and nutrition of the heart. If any group of
muscles is greatly overstimulated and overworked, the result is secon-
dary wasting and paralysis, and the heart is no exception to this law.
The remedies belonging to this class are Digitalis, Convallaria, Adonis,
Caffeine, Coca, Secale, Squilla, and Erythrophleum. These are the most
potent. There are others which have a similar effect, but in a less de-
gree, not being as dangerous or injurious in their action. Of these, As-
paragus, Asclepias, Stigmata maidis, Juniper, Euonymus, Prunus virginian.
448
A SYSTEM OF MEDICINE.
and Prunus cerasus, Apocynum, and many others. I have already given
the special and general indications for these medicines in the article
on Valvular Diseases, to which I refer the reader.
It remains to mention the medicines best adapted to the treatment
of the sequelæ of dilatation.
Cerebral anæmia is best removed by Caffeine 1', Coca 9, Ferrum, small
quantities of alcohol, and an abundance of good food.
Congestion of the liver, i. e., that passive condition caused by a weak
heart, when the arteries of the liver are unfilled, and the veins turgid,
require Digitalis, Adonis, Convallaria, and Euonymin, in appreciable
doses, because they are capable of causing the heart to force more
blood into the empty arteries, and push the blood along the turgid
veins. Under their use, the enlargement of the liver and the jaundice
will disappear. We may often aid them, by alternating with one or
the other some specific hepatic medicine like Mercury, Podophyllin,
Iridin, Chelidonium or Chionanthus.
The Dropsy.-Cardiac dropsy is a result of a failure of the heart's
power. The kidneys become anæmic of arterial, and congested with
venous, blood, and the secretion of urine is arrested. Renal remedies
are of palliative value only in cardiac dropsy, and, if pushed to any
extent, they may injure the integrity of the kidneys. If there is any
muscular tissue left in the heart, the dropsy may be removed by the
bold and judicious use of Caffeine, Digitalis, Convallaria, Adonis, and
Squills. They may be greatly aided by Stigmata maidis, Juniper, Apo-
cynum, Asclepias, and Asparagus, but these latter (except corn-silk)
cannot be trusted alone.
Dyspnoea has, in my hands, yielded more readily to Convallaria
than any other remedy. Dr. See, of Paris, prefers Erythrophleum.
Others prefer Quebracho (see Valvular Diseases). Dr. See advises Con-
vallaria with Iodide of Potassa in some cases. Small doses of Tartar
emetic often give relief when the dyspnoea is partly due to accumu-
lated mucus in the bronchi. Ipecacuanha, for the same condition.
Lobelia has given good results, but in large doses it is a cardiac de-
pressant. Arsenic has rarely been of benefit in my hands. Grindelia will
sometimes act admirably; so will Euphorbia piluifera, an Australian
species. In desperate cases, when it seems there must be death if no re-
lief comes, Chloral hydrate, 5 to 10 grains every hour, has given pallia-
tive results. Morphia or Morphia and Atropia combined, will palliate
the terrible suffering in incurable cases. Sometimes, the Aromatic Spirits
of Ammonia will act well when all other palliative remedies fail.
I mention these palliative measures to be used in incurable cases,
because it is the duty of the physician, when he cannot cure, to save
his patient all the suffering possible, and this without the slightest
regard to pathies or schools. In this condition, when we know that
death is only a little way off, all drugs are at our command, and we
DISEASES OF THE ORGANS OF CIRCULATION.
449
are faithless to our trust if we do not use those which will "smooth
the pathway to the grave."
FATTY OVERGROWTH OF THE HEART.
BY H. R. ARNDT, M.D.
Synonyms.-Fatty hypertrophy, Fatty infiltration; French, Hyper-
trophie graisseuse du cœur; German, Fettige Infiltration des Herzens.
Definition.-An abnormal growth of fat upon and within the sub-
stance of the heart, mechanically interfering with the proper perform-
ance of the functions of the organ.
Ætiology.-Fatty overgrowth of the heart seems to be a local ex-
pression of a general constitutional tendency to obesity, which, in
many cases, is hereditary. Whatever tends to produce obesity tends
to produce fatty infiltration of the heart. The habitual use of fat-
making diet, as starchy, saccharine, and fatty substances, and the free
use of alcohol in any form, but particularly of malt-liquors, are im-
portant ætiological factors. A sedentary, inactive life predisposes to
the same condition, and recovery from a tedious acute disease, neces-
sitating long confinement and a period of enforced inactivity, not in-
frequently is followed by obesity and fatty infiltration of the heart.
This condition, according to reliable tables prepared by Quain and
Hayden, is very much more common in men than in women, and is
rarely found in persons under thirty years of age. As exceptions to
these general rules, it may be stated that Kerkering noted the existence
of excessive fatty overgrowth in an infant only two years old; and
Quain mentions one case in a table of twelve "in a person who was
described as being thin."
Pathology. Whenever an abnormal amount of fat exists in the
heart, it is found lying between the muscular fibres, separating them
from each other, encroaching upon them, and gradually thinning and
weakening the muscular walls of the organ. The deposit of fat is most
abundant on the external surface, and grows less and less as the surface
is left; thus, the outer surface presents the largest amount of fatty
growth and the smallest number of muscular fibres, while the inner
surface presents the smallest amount of fatty deposit and the largest
number of healthy muscular fibres. Small fatty tumors are frequently
seen beneath the endocardium, and in cases in which the fatty deposit.
is not uniform or excessive, streaks of fat, yellowish in color, may be
observed lying between the muscular structure.
The presence of this foreign matter necessarily creates pressure upon
the muscular fibres, which become distorted and, at times, suffer fatty
degeneration; it also interferes with nutrition, and mechanically hin-
ders the performance of the physiological function of the heart.
VOL. J.-29
450
A SYSTEM OF MEDICINE.
Symptoms.-The symptoms of fatty growth on the heart very
closely resemble those of fatty degeneration. If the fatty deposits are
confined to the surface of the organ, serious harm may not result, and
the condition may even go unrecognized; but if the substance of the
heart is involved, we get weakness of the organ with vertigo, coma,
dyspnoea, pain, and other symptoms discussed as due to fatty degen-
eration, the case terminating fatally, from failure of the heart's action
or from rupture. Death usually occurs suddenly.
Diagnosis. The diagnosis of fatty growth of the heart is exceed-
ingly difficult; we may conjecture its existence from the physical signs
and the constitutional symptoms which indicate fatty degeneration
occurring in very obese persons. The differential diagnosis, if made,
is, however, more a matter of personal satisfaction to the physician
than of practical interest to the patient.
The treatment of fatty overgrowth on the heart will be considered in
connection with the treatment of fatty degeneration of the organ.
FATTY DEGENERATION OF THE HEART.
BY H. R. ARNDT, M.D.
Synonyms.-Fatty metamorphosis of the heart, Greasy degenera-
tion of the heart, Softening of the heart; (French) Dégénérescence du
Cœur; (German) Fettige Metamorphose des Herzens.
Definition.-Fatty degeneration, as defined by J. Mitchell Bruce,
is a process by which protein elements are converted into granular
fatty matter. Fatty degeneration of the heart refers to such a process
in the heart, the muscular fibres gradually disappearing, and eventu-
ally being replaced by fatty matter. This change depends upon inter-
ference with proper nutrition of the fibres, and is the result of various
morbid conditions tending to disturb the normal nutritive process.
Etiology. Any condition, local or constitutional, which interferes
with the nutrition of the heart-fibre, eventually leads to fatty degen-
eration of this organ. The promptness with which this effect is produced
depends somewhat upon the existence of the predisposing causes, among
which inherited tendency, age, sex, and habits of life stand prominent.
It seems fairly well established that members of certain families are
quite likely, sooner or later, to suffer from this affection. It is evident
that this predisposition must depend either upon some inherited
peculiarity of the muscular fibre itself, in itself tending to fatty de-
generation, or upon a family tendency to constitutional diseases which
act as an exciting cause by interfering with the nutrition of the heart-
fibre; the latter presumption seems most likely to be correct. Age ist
an important factor. At a time of life when the general tendency of
DISEASES OF THE ORGANS OF CIRCULATION.
451
the entire body is toward degeneration, we are justified in looking for
such changes in the ever busy heart-muscle. The great majority of
cases occur in the latter half of life, and of them a very large propor-
tion in advanced old age. Young persons and children, however, are
not exempt, and even foetal life is not entirely free from it. Men are
more frequent sufferers than women, in proportion of about two to
one; according to Ponfick, an exception should be made in favor of
cases resulting from anæmia, a condition more frequently found in
women than in men. Persons engaged in sedentary occupations are
said to suffer readily from fatty degeneration of the heart, and statis-
tics show that the lower walks of life furnish a large percentage of
sufferers from this condition; fat people, merely on account of their
tendency to the accumulation of fat, are not especially predisposed to
softening of the heart.
The exciting causes, as has been stated, embrace all those various
local and constitutional affections which interfere with the proper
nutrition of the heart-fibre. Whenever the blood vessels of the heart
become subject to pressure, as from the existence of foreign growths,
or when vascular obstruction exists, due to disease of the vessels
themselves or as the result of embolism, the blood-supply to the
muscular structure is lessened, and degenerative changes occur; these
changes are limited, as pointed out by Quain, to that portion of the
heart which is supplied by the affected vessel. Tumors, fibroid or
fatty, may press directly upon the muscular fibre itself, leading to the
same result. A condition of congestion or hypertrophy of the walls
of the heart necessitates an unusually free blood-supply, which taxes
severely the carrying capacity of the vessels, especially when the latter
are compressed by tumors or subject to alterations in the structure of
their coats; the supply becoming insufficient, the integrity of the
muscular fibre is soon lost, and fatty degeneration results. Gowers
(Reynolds's System of Medicine) refers to Jenner, who considers that the
chief cause of congestion of the walls of the heart is "dilatation of the
right side of the heart and obstruction, consequent on the distension
of the auricle, to the escape of the blood from the coronary sinus.
Hence, fatty degeneration of the heart is frequent in emphysema, long-
continued pleural effusion, and diseases of the left side of the heart,
which overload the right chambers."
Among the constitutional exciting causes, anæmia holds very promi-
nent place. Any condition which results in a lessening of the total nor-
mal amount of blood, such as a profuse hæmorrhage, or which lowers
the nutritive properties of the blood, threatens the integrity of the
heart-structure. The experiments of Tschudnowsky and Perl, made
upon dogs, show conclusively that the sudden loss of a large amount
of blood has most disastrous consequences upon the heart, leading to
fatty metamorphosis of the walls of the heart, and even of the blood-
452
A SYSTEM OF MEDICINE.
vessels. This fact shows the peculiar danger of menorrhagia, or violent
flooding during or after confinement, especially in women already
anæmic or suffering from cardiac hypertrophy.
Fatty degeneration also occurs in certain specific fevers, and by a
majority of observers is held to be the result of a coexisting, more or
less violent, carditis. According to Quain, the tissues of the heart,
during these fevers, become softened, and under the microscope pre-
sent "a granular appearance, which is believed by some pathologists
to be an incipient stage of fatty degeneration." That fatty degenera-
tion may result from inflammatory action is a well-established fact.
Wagner, for instance, examined thirty-five cases of severe pericarditis
and found that one-half of them showed extensive fatty degeneration.
The extent of the degeneration depends upon the violence and dura-
tion of the inflammation. On the other hand, it is maintained that
the same type of degenerative change occurs when there is absolutely
no evidence of inflammatory action in the heart, and when blood-
poisoning is evidently the prime factor. Laennec calls attention to
the fact that fatty degeneration of the heart occurs particularly in
cases marked with "putridity." Among the febrile diseases which
most commonly excite fatty degeneration of the heart, mention is to
be made of malarial fever, typhus, typhoid, yellow fever, diphtheria,
measles, etc., and of that class which is characterized by extensive
formation of pus, as variola, erysipelas, etc.
Of the chronic diseases, those which lower the standard of vitality,
or which lead to alterations in the blood, may become exciting causes;
extensive suppurations, cancer, and certain diseases of the kidneys
belong here.
Several poisonous substances have the power to produce fatty de-
generation in the heart as well as in the liver, kidneys, and in other
parts. To this class belong phosphorus, arsenious acid, sulphuric
acid, lead, antimony, and alcohol.
Anatomy and Pathology.-Fatty degeneration always begins in
the protoplasm of the cell, gradually involving the nucleus and the
nucleoli. At first, small numbers of fat-globules, clearly defined,
never coalescing, and separated, throughout the various stages of their
development, by thin layers of protoplasm, are seen about the nu-
cleus; their number gradually increases, until they fill the entire
cell, rendering the nucleus first indistinct, then wholly invisible; the
cell, in the mean time, enlarges until it attains to several times its
former size, and its original cylindrical, or flat, or round form, becomes
uniformly spherical. The cells now are called "granular corpuscles,"
a term of somewhat recent origin which has taken the place of the
"inflammatory corpuscle" of older writers.
In the heart, this degeneration first appears as minute, black gran-
ules in the striated fibre, gradually increasing in size, but rarely ex-
DISEASES OF THE ORGANS OF CIRCULATION.
453
ceeding that of a blood-globule. They are arranged in rows, "like
strings of pearls," in the longitudinal axis of the primitive fibrillæ ;
in due time the transverse striæ also become indistinct, and are finally
lost. If the degenerative process advances far, nothing is seen but
fatty detritus. The arrangement of the granular corpuscles, however,
is by no means uniform. They may be arranged, as stated, longitu-
dinally in quite even rows; or they may appear scattered promiscu-
ously through the affected tissues; numbers of the primitive bundles
may contain large amounts of the granules, while others have pre-
served their structural integrity; even a separate fibre may be studded
with granules at some portion, while it is perfectly healthy in other
portions.
To the naked eye, tissue thus affected presents a whitish-yellow ap-
pearance, or of an ashy-gray color. Laennec compared the color to
that of "a dead leaf." Discolorations of a yellowish-brown are not
infrequent, and are due to the action of the coloring-matter of the
blood-corpuscles upon the tissues, a frequently occurring condition in
fatty degeneration of the heart which depends upon acute febrile
diseases.
The fibre itself becomes brittle, the diseased structure flabby and soft,
and, if the degeneration is well advanced, it tears easily, in fact, as Quain
states it, as easily as wet brown paper. In certain cases, particularly
-cases in which hypertrophy of the part antedates fatty degeneration,
the organ has the appearance of firmness and solidity of structure,
but the tissues have, nevertheless, lost their integrity, and break down
from slight causes, as pressure from careless handling.
Quain, one of the best authorities upon the subject, describes a con-
dition of the fatty heart in which it resembles boiled liver, and calls.
attention to a granular appearance of the cut surfaces, which is not
unlike the gray hepatization of lung-tissue.
The affected part at times has a greasy appearance or " feel," and,
if placed upon paper, may leave upon it an oily, greasy stain, although
the actual amount of oily matter present may be little, if any, more
than the amount of fat found in the healthy heart.
The size of the fatty heart may be enlarged, normal, or even below
normal. Quain and Hayden have found the heart enlarged in two-
thirds of the cases of fatty degeneration examined by them. It is
well to bear in mind the relation of hypertrophy to fatty degeneration,
and the fact that the "looseness" of the structure would naturally
tend to convey the impression of an actual enlargement, even when
an enlargement does not exist.
Usually, fatty degeneration of the heart takes place in limited and
well-defined areas, distributed here and there, possibly connected by
well-marked lines of degenerated tissue, the whole giving to the organ
a mottled, spotted appearance, visible on section or through the endo-
454
A SYSTEM OF MEDICINE.
cardium. But the entire organ may be uniformly affected, as occurs
in cases of fatty degeneration resulting from acute disease. The left
ventricle suffers more frequently than the right, in proportion of two
to one, and the columnæ carneæ and the inner layers of the muscular
walls show the traces of the degeneration more clearly than other
structures. The depth also to which the degenerative process extends
into the heart-wall is not the same in all cases, and seems to depend
upon the primary disease of which the fatty degeneration is the re-
sult; thus, fatty degeneration following pericarditis is superficial, that
resulting from certain chronic affections is more likely to involve.
the deeper structures. When the fatty metamorphosis depends upon
a diseased condition of a bloodvessel, cutting off, or lessening greatly,
the supply of nutritive fluid, the affection is limited in extent of ter-
ritory, is clearly defined, and, usually, well-marked in character.
Calcareous salts may be deposited in the heart-muscle as one of the
incidents of fatty degeneration; but such cases are very exceptional.
Coats (Glasgow Medical Journal, 1872) describes one case in which
petrifaction of the fibres, without change of form, had taken place,
and one in which the fibres were dotted with small spherical bodies of
calcareous matter.
While all authorities agree that fatty degeneration means practically
starvation of tissue, and even death, the utmost differences of opinion
exist concerning the nature of the process which is really responsible
for the changes produced. Rindfleisch (A Text-book of Pathological
Histology, American edition, by Lindsay & Blakiston, 1872) says:
"The chemico-physical process which lies at the basis of the fatty
degeneration of the cells, is not indeed known with sufficient per-
spicuity. In the mean time we may set aside the opinion that the
fat-globules can attain the interior of the cells by intussusception;
the fact that muscle, in which we recognize a medium degree of fatty
degeneration, nevertheless does not exhibit a greater percentage of fat
than does the normal, controverts this. The possibility only remains
that the fat-globules originate in the interior of the cell. But are they
to be regarded as the production of a disturbed exchange of material
of the cell, or as the products of decomposition of the cell-substance?
The view seems mostly to recommend itself that we are investigating
phenomena the opposite of those which accompany the cell-forma-
tion. As we know from the composition of the yolk, the formative
material of the cells consists of albuminates, which are abundantly
mixed with fats. We further know from the chemical analysis of
muscular fibres that they contain a not inconsiderable amount of
invisible fat, so that we have reason to accept an amalgam-like combi-
nation of fat and albuminates in the cells. Fatty degeneration is a
reseparation' ('Wiederscheidung') of this amalgam, in which the
fat again appears free and in large globules in the protoplasm. That
(
DISEASES OF THE ORGANS OF CIRCULATION.
455
an appreciable enlargement of the cell occurs herewith is explained
by this that the same amounts of fat and albumen, in order to exist
separately, take up a greater space than in their former interpenetra-
tion."
The fact that in case of advanced fatty degeneration the amount of
fat contained in a tissue is very largely in excess of the normal quan-
tity, has led to a search for additional evidence bearing upon this
point. And while the views expressed by Rindfleisch are warmly
advocated by many eminent pathologists, it is now generally held
that this remarkable excess, in advanced cases of fatty degeneration,
is also in part due to a change in, or transformation of, the protein
matter, or to the entrance into the fibre of fat from without.
It is evident that so serious a disorder of so important an organ as
the heart must give rise to very important and characteristic effects.
The entire circulatory system necessarily becomes deranged, and the
nutrition of all the organs of the body suffers keenly, producing
marked symptoms which will be duly considered hereafter. The irre-
parable injury done to the fibre leads to dilatation of the heart, and
very frequently to rupture of the organ.
Symptomatology.-The symptoms of fatty degeneration of the
heart are rarely sufficiently pronounced and characteristic to lead to
the prompt recognition of this serious affection; in fact, cases have
occurred in which extensive degeneration had existed, evidently for
some considerable length of time, and had led to a fatal termination
without giving rise to disturbances of a sufficiently grave character to
arouse the suspicion of the patient or physician. The nature, too, of
the symptoms observed depends largely upon the nature of the pri-
mary disease of which the fatty degeneration of the heart is a sequence,
and their clearness is often greatly disturbed by coexisting affections
producing a train of morbid phenomena which only too often over-
shadow the expressions of the affection of the heart.
In a general way, it may be stated that the constitutional symptoms
depend upon insufficient blood-supply, and even in the earlier stages
express a marked depression of the physical and moral sphere. The
patient at first experiences a general indisposition, muscular weakness,
coldness of the surface and of the extremities, with occasional irregu-
larity in the action of the heart, and, later, oppression of breathing.
The appetite becomes impaired, digestion proceeds without vigor, and
the mental state becomes one of habitual depression. The pulse be-
comes intermittent and irregular, weak and slow, and if its irregularity,
which is almost constant, disappears for a time when the patient seems
in the enjoyment of comparatively good health, it is reproduced at
once by trivial causes, such as passing emotions. (Quain.)
Kennedy calls attention to a rapid pulse which increases with age,
and which he considers often an indication of fatty degeneration of
456
A SYSTEM OF MEDICINE.
the heart. Faintness not unfrequently occurs, brought on by slight
effort, such as walking up-hill, or climbing stairs; it may be merely a
passing sensation, or result in complete syncope, probably the result
of cerebral anæmia; the occurrence of severe vertigo, and even con-
vulsions, not however followed by evidence of lesion in the brain, has
been noted in cases. As anæmia of the brain may result from the
inability of the weakened heart to supply this great nerve-centre with
the needed amount of blood, so may we find anæmia of the spine,
giving rise to characteristic disturbances, as formication and numb-
ness. These attacks of faintness and of actual loss of consciousness
are very commonly accompanied with a sense of impending death,
and, indeed, death frequently occurs at such times. Respiration is
usually affected, varying from a scarcely noticeable feeling of discom-
fort, with unconscious sighing, to a suffocative feeling, readily brought
on by any moderate exertion, more especially by walking up-hill.
The "Cheyne-Stokes dyspnoea," of which mention must here be made,
Gowers (Reynolds's System of Medicine, vol. ii., p. 817) describes as fol-
lows: "It is characterized by recurring series of respiratory acts, first
increasing and then decreasing in intensity. In the intervals breath-
ing seems to have almost or entirely ceased; then slight respiratory
movements are noticeable, which gradually become deeper and deeper,
until an acme of very deep and labored breathing is reached, after
which the respirations gradually become shallow until they subside.
into the same apparent apnoea, which is again broken by the gradual
onset of another series. In the classical case recorded by Cheyne, the
cycle included about thirty respirations, and lasted a minute. In
most of the other cases recorded it has occupied a shorter time."
Hayden has found the pulse unchanged during the paroxysm. The
same writer also emphasizes the fact that this form of dyspnoea is not
diagnostic of fatty degeneration of the heart, but is also found in val-
vular disease with dilation, in atheroma of the aorta, in certain affec-
tions of the nervous system, particularly when coexisting with diseases
of the heart, and that it depends probably, as suggested by Walshe
and others, upon a lowered sensibility of the respiratory centre in the
medulla oblongata. The pulse-beat is usually light and feeble, with
an occasional wavering quality; its beat is slower than that of the
heart, if the force of the latter is not sufficient to send the blood on-
ward with sufficient vigor. As these symptoms develop, more or less.
pain in the region of the heart or in the sternum may exist, not
usually sufficient to cause much distress; at times, the pain becomes
neuralgic, and extends into the arm, or even into the shoulders, and,
in exceptional cases, paroxysms of intense pain are experienced, which
closely resemble angina pectoris. During the later stages the counte-
nance and surface of the body becomes pallid, and the ankles and feet
become puffy; but no general dropsy occurs, nor does the urine show
DISEASES OF THE ORGANS OF CIRCULATION.
457
abnormal constituents save when albumen is found in cases of primary
dilatation.
The heart itself presents no pathognomonic, and hardly any strongly
diagnostic, symptoms. If dilatation exists, the area of dulness on per-
cussion is correspondingly increased. Since the degenerative process
itself tends to weaken the heart, the force of its beat necessarily
decreases as the integrity of its muscular wall is lost; hence, in place
of a firm contraction, the beat is sluggish, badly defined, almost
hesitating, resembling, as Stokes has it, the slight, general impulse of
an aneurism rather than the normal impulse of the heart. Naturally,
this lack of force leads to modifications of the heart-sounds.
"The
sounds of the heart are weakened in correspondence with the weak-
ness of the impulse. The first sound, to which the contraction of the
heart directly contributes, is that which presents the greatest change.
It is usually toneless, shorter, and relatively high-pitched, and may
become almost, or even quite, inaudible at the apex, only the second
sound remaining. The first silence is longer than normal, in conse-
quence of the shortening of the first sound. The second sound is also
weakened in consequence of the deficient distension, and therefore
deficient recoil, of the aorta and pulmonary artery. When the first
sound is shortened and raised in pitch, it may resemble the second.
The sounds of the foetal heart are then closely simulated, especially if
the heart acts rapidly. When the degeneration is local, the sounds
may be modified locally, just as the impulse. In the acute degenera-
tion of fever, Stokes observed that the first sound might be lost over
the left ventricle when it was still audible over the right, in cases in
which the post-mortem examination showed the left ventricle to be
the more affected. Walshe has observed a similar alteration of inten-
sity in chronic disease under similar circumstances. . . . . Stokes
believed that a systolic basic murmur might exist during the early
stage of the degeneration. Other observers have noted the occurrence
of an apex murmur due to regurgitation, and have ascribed it to fatty
degeneration of the papillary muscles." (Gowers.) The rhythm of the
heart is inclined to be irregular, and may present no abnormal features
as to rapidity or slowness of movement; if it deviates markedly from
the normal, it is more often rapid in movement; but cases are on
record in which the heart gave but forty, thirty, and even less, beats
per minute, a condition, as pointed out by Adams, which is almost
limited to this affection.
Diagnosis.—A positive diagnosis of fatty degeneration of the heart
is not only very difficult, but practically impossible. Presumptive
evidence in favor of fatty metamorphosis of the heart is found in the
existence of those conditions which are recognized as exciting causes,
and of symptoms which are known to indicate a constitutional ten-
dency to fatty degeneration in any part of the body. Among the
་
458
A SYSTEM OF MEDICINE.
latter mention may be made of characteristic changes in the blood-
vessels of aged people, and of the arcus senilis, a crescent-like opacity
in the upper and lower segment of the corneal circumference; the
arcus senilis, however, is not of the diagnostic value of the changes in
the bloodvessels which may be detected by a skillful diagnostician,
and it often exists in the absence of cardiac affection.
The physical signs have been described as a part of the symptom-
atology of the affection. They are by no means pathognomonic, since
they offer no valuable guide to differentiation between fatty degenera-
tion and simple hypertrophy and dilatation of the heart. Of the
physical signs, the one of most value is the weakness of the first heart-
sound, to which attention has already been called.
Duration and Prognosis.-The duration of this condition, and
the chances of a favorable or unfavorable termination, depend almost
wholly upon the nature of the primary cause. When occurring in
connection with, or depending upon, an acute disease, there is con-
siderable immediate danger of an untoward and sudden termination;
this immediate danger overcome, the patient may recover largely, if
not entirely, from the effects of the local injury. If, as in cases of
alcoholism, the cause of the difficulty can be wholly removed, the
prognosis is favorable. In the aged, fatty degeneration may exist for
many years without giving serious inconvenience; and while the
eventual termination is quite sure to be fatal, a restful and contented
state of mind, with abstinence from much physical exertion, will, for
a long time, protect the life of the afflicted person. Fatty degenera-
tion of the heart resulting from loss of blood terminates fatally within.
a few days or a few weeks from the occurrence of the hæmorrhage.
If the degeneration of the heart is only one part of a general degenera-
tive process, associated, for instance, with extreme anæmia, loss of
appetite, and great physical prostration, the prognosis is decidedly
discouraging.
Death from fatty degeneration of the heart is more frequently sud-
den. Of eighty-three cases collected by Quain, sixty-eight died sud-
denly; syncope, rupture of the heart, and coma, in the order of their
mention, are the immediate causes of death.
The tendency of Chloroform to seriously depress the action of the
heart, and the evident danger therefore arising from its administration
to persons in whom the existence of fatty degeneration of the heart
may be suspected, has been repeatedly pointed out by Quain, and
confirmed by himself and others.
((
Treatment.*—Fatty heart is defined as a growth of fat on the sur-
face and in the substance of the heart, in quantity sufficient to inter-
fere with its functions." Thus it will be seen that the treatment of
* By E. M. Hale, M.D.
DISEASES OF THE ORGANS OF CIRCULATION.
459
fatty heart is essentially the treatment of obesity, for it has no relation
to true fatty degeneration of the fibres of the heart.
If, on examination, the heart is found structurally sound, if the
pulse be strong and regular, if auscultation and percussion show it
to be free from hypertrophy, dilatation of the valvular lesions; the
aorta healthy, as shown by the quality of the cardiac sounds in the
ascending aorta, and the character of the respiration; if the kidneys
are free from disease, as shown by careful general and microscopical
examination of the urine; under these circumstances the treatment
may be advised as follows: Active exercise, especially that which
quickens respiration and consumes heat-producing tissue; the use of
dumb-bells, Indian clubs, "Swedish movement cure " processes, etc.
The diet should be restricted to wholesome nitrogenous food, and
the use of hydrocarbons, fat, and sugar be prohibited. Milk and
malt liquors must be forbidden. No full meals, i. e., to satiety, should
be indulged in. Cold or tepid baths should be taken frequently. The
bowels should be kept open daily by the use of Carlsbad, Kissingen,
Congress, or Hawthorn waters, for these waters have a large influence
in preventing the deposit of fat, while they do not reduce mus-
cular strength. The "Banting system" involves no little danger to
the integrity of structures and organs, especially those subject to
periodic and frequent distension, such as the heart and arteries, by the
attenuation and weakening of their walls which necessarily follow the
rapid removal of interstitial and superficial fat. The adipose tissue
should be gradually removed. The slow sipping of hot water, 3 viii.
(temp. 90° to 100°), thirty minutes before each meal, has a notable.
effect in reducing adiposis if the diet is regulated as above mentioned.
The drinking of natural sea water, four ounces after each meal, has
been known to cause similar reduction of fat. The use of the extract
or infusion of Fucus vesiculosus, a species of seaweed, has been attended.
by excellent results (see Therapeutics of New Remedies). Calcarea carb.,
Graphites, Lycopodium, and Ferrum phos., in minute doses, antidote
the tendency to adiposis. The use of the Iodides and Bromides, or
Acetic acid, is not a safe practice, for, while the fatty deposits may be
removed, the muscular structures may be seriously injured.
The treatment of fatty degeneration, when the muscular fibres are de-
stroyed by a process of disintegration, and their place supplied by oil
globules, requires very different treatment. Any treatment of this form.
of degeneration is of very doubtful value. We cannot build up new
muscular tissue in the place of that destroyed. The most we can hope
for is to arrest the retrograde metamorphosis. At least this is the
opinion of the most eminent writers. What therapeutical discoveries.
may do to assist us in the treatment of this disease we do not know.
In the matter of diet and exercise we should pursue a course opposite
to that advised for fatty heart. The diet should be very nutritious;
460
A SYSTEM OF MEDICINE.
fatty food is not objectionable. Even cod-liver oil may be used with
benefit. So may malt liquors in moderation, but alcohol cannot be
allowed, especially in the form of brandy, whiskey, gin, or strong
wines. The red wines and Tokay or Rhine wines may be allowed.
The digestive processes should be kept in good order, and the blood
enriched by blood-making food, and the use of chalybeate waters,
Ferrum, Helonin, Aletris, Columbo., Gentian, Ignatia, Nux vomica,
China, and all those remedies which favor complete assimilation of
food, and by their action on the nerve-centres increase the tonicity of
muscular tissues.
The question here arises, of great importance to our school of medi-
cine: Are there medicines which are strictly homeopathic to fatty degenera-
tion? The answer is yes. Then the question occurs: Are these medi-
cines curative? This cannot yet be answered in the affirmative, because
not sufficient clinical experience has been collected to allow of an an-
swer either way. The following drugs have been known to cause fatty
degeneration of the heart and of other organs: Phosphorus (Wagner,
Habershon, Schraube, and others); Arsenic (Salkowsky and other
toxicologists); Plumbum (Salkowsky and other toxicologists); Anti-
mony (Salkowsky and other toxicologists). The acids, phosphoric,
nitric, sulphuric, oxalic, tartaric (Koch, Rokitansky, Lewin, Tangel,
Wagner, and others). Alcohol, Chloroform, and Ether (many authori-
ties). Iodoform. Dr. Hoepff found in post-mortem examination in
four cases of death from Iodoform-poisoning a condition of fatty de-
generation of the heart, liver, and kidneys. The process was only
beginning in some, but far advanced in others. The author then insti-
tuted a series of experiments on rats, guinea-pigs, and rabbits, adminis-
tering to them, subcutaneously, injections of Iodoform in oily solu-
tions. In every case he found parenchymous inflammation of the
heart, liver, and kidneys (Allgem. Med. Central Zeitung, Aug. 8, 1883).
Now; at a superficial glance, all these drugs appear to be homœo-
pathic to fatty degeneration. But we must look deeper into their
action before we decide. Does this morbid action depend on a true
medicinal, dynamic, and specific influence? Or is it a chemical action?
If it can be proved that the former is their modus operandi, then they
are really homoeopathic. But if this change is caused by a chemical,
or chemico-physiological, action, then they are not truly homœopathic,
in the sense understood by Hahnemann.
Phosphorus has been used successfully in many heart affections. Dr. Cl. Mueller
highly recommends it in chronic affections of the heart, Buechner recommends it in
diseases of the right heart, in connection with morbus Brightii. Singularly, Dr.
Quain (Dic. of Medicine) recommends Phosphorus in fatty degeneration of the heart!
I can find no record of its use in this disease in our literature, but I am inclined to be-
lieve that it is truly homoeopathic to this disease.
Arsenic is recommended and successfully used, by both schools, in chronic car-
diac diseases. It presents a large array of symptoms which point to degeneration of
the hearts structures, and appears to be truly homoeopathic to its condition.
DISEASES OF THE ORGANS OF CIRCULATION.
461
Plumbum is recommended by Bæhr (Therapeutics), who gives a large array of
symptoms indicating its use, which present a good picture of fatty degeneration; but
he gives no clinical proofs of its value.
Antimony presents us with cardiac morbid symptoms similar to those of Ar-
senic. The Arsenite of Antimony has been recommended by French physicians as a
cardiac tonic, but I can find no clinical experience relating to its use in our school.
"Prof.
Iodoform has lately been found to be a "heart-tonic" in small doses.
Testa (Giornalo di Med è. Ter. di Messine) has reported some observations made by
him on the curative effects of Iodoform in organic diseases of the heart. He has
studied the subject for several years, and has observed the effect of the drug in a num-
ber of cases. The remedy is not directed against the lesions themselves, but rather
against the effects produced by them. He gives the drug in pill form, every two
hours, until one grain is taken during the day. Its most marked effect is to diminish
the number of heart-beats while it increases the arterial tension." Now it may be that we
have in Iodoform a specific homeopathic remedy to some cases of fatty degeneration.
In the Iodine-pathogenesis we find many symptoms of this disease. Iodine, like Ar-
senic and Phosphorus, will cause degeneration in all the organs of the body, accom-
panied by deficient innervation of the general system. I have given Iodoform in
many diseases, in doses of to ʊ grain, for months, and have never observed other
than restorative effects. Under its use the general nutrition increased, and the heart's
action improved in a decided manner.
T
The action of the acids in causing fatty degeneration is suggested by
Fothergill to be chemical. He thinks they act by "depriving the
nitrogenized tissues of their ammonia, and thus leaving the other con-
stituents as fat." Virchow found the blood positively acid in all
pyæmic or septic conditions. It may be that the development of cer-
tain acids in the blood tends to fatty degeneration of the heart. If
such be the case, the internal use of ammonia might be of value to
prevent or arrest that condition. But aside from curative agents, there
are at our command many palliative measures. The same hygienic
rules should be followed as those laid down in the treatment of dila-
tation. The remarks relative to pure air, climate, etc., are equally
applicable to this disease.
Of palliative or restorative remedies, I know of none that equal
Strychnia. It matters but little whether we give this agent in the form
of Nux vomica or Ignatia, if we give enough to get the specific physio-
logical (not toxic) action of the drug. Strychnia, like Digitalis and
others of its congeners, acts upon the heart, but unlike Digitalis, it
acts on that organ not by direct stimulation of the intercardiac ganglia
and the branches of the sympathetic, but through the spinal cord. In
its ultimate action it tetanizes the heart and the muscles of respiration.
It is a spinal cardiac tonic.
In medicinal doses it not only strengthens the remaining muscular
fibres of the heart in fatty degeneration, but it strengthens the respira-
tory muscles and regulates their action. It relieves the dyspnea in
this disease more than any other remedy. It is not as potent to regu-
late the rhythm of the heart as are Digitalis and Convallaria, but it is a
safer remedy to increase the working power of the heart. The dose
need not exceed one grain of the 2 trituration, and one grain of the
31, repeated three or four times a day, will, in some cases, be amply
sufficient. In cases in which the rhythm is impaired, and we find great.
462
A SYSTEM OF MEDICINE.
irregularity, intermittency, with weakness of the heart's contractions
and the respiratory muscles (apnoea), I have seen the best results.
follow the use of the tablets of Digitalis and Strychnia heretofore re-
ferred to. (Each tablet contains grain of the leaves or extract of
Digitalis, and grain of Strychnia.) One may be given every four
or six hours until relief is obtained, and then three times a day for
weeks.
The heart's beats in this disease are sometimes phenomenally slow.
In such cases I have found Veratrum viride 3º of value, if the pulse was
large and full. When the pulse is small, Laurocerasus is better indicated.
Picric acid in one case quickened the pulse (of 50) and removed other
symptoms found in its pathogenesis. Sanguinaria is indicated for
very slow pulse with vertigo. Digitalis, the stock-remedy for slow pulse,
has not been of any benefit in my hands, unless the pulse was inter-
mittent. Strychnia quickens the pulse when slow and very weak, with
cold extremities, etc. The syncopal attacks are best relieved by the
horizontal posture and the cautious use of Nitrite of amyl or Glonoine,
especially when anginal pain is present, or by Aromatic Spirits of Am-
monia, when cold sweat and persistent faintness occur. The patient
must be cautioned to avoid all such efforts as straining at stool, lifting
weights, pulling on boots, running upstairs, or standing too long on
the feet. Many sudden deaths occur from such efforts. Chloroform
or Morphia should never be used. The sighing respiration (Cheyne-
Stokes breathing) is best palliated by Atropine 3*.
The muscular tremulousness, mentioned by Fothergill, I have fre-
quently seen in cases under my care. Some cases I have relieved by
Calabar 3, others by Zinc. phosphide 2*, and some by Cocculus 3. I am
sure that the use of Coca in some form has greatly benefited many
cases of this disorder, and I would advise its use in the form of an in-
fusion of the leaves, if good leaves can be procured, instead of coffea
or cocoa. Tea and tobacco should be absolutely prohibited when there.
is even a suspicion of the presence of fatty degeneration.
ADVENTITIOUS PRODUCTS, CYSTS, ETC.
We here include all morbid growths not generally treated by them-
selves. The first, and perhaps most frequent, is
Cancer, or carcinoma, sarcoma, epithelioma, melanosis. It occurs
rarely in any case, and though perhaps occurring primarily, an orig-
inal cancer can generally be located in some other part of the body.
Middle life has the largest per centum, and males show a greater pro-
portion than females.
Anatomy. There is no particular locality for cancerous growths,
though the right heart has been more generally affected; the external
DISEASES OF THE ORGANS OF CIRCULATION.
463
surface seems preferred to the endocardium, and the adventitious
growth should easily be distinguished from the normal heart muscle,
though in every case section and the microscope should be brought
into play. Cancer may cause endocarditis or ulceration.
Symptoms. There are rarely any special symptoms attainable;
only general constitutional disturbances are noticed, and the neces-
sary symptoms of præcordial pain, dyspnoea, and angina-like seizures.
Diagnosis.—Diagnosis of cancer of the heart has never been made
during life, though the occurrence of heart disturbances during the
course of cancer in another part may indicate that the heart is in-
volved. Death is certain and may be sudden.
Lymphoma has been met with in cases where this disease was
general; it is of no interest whatever, save from an anatomical stand-
point.
Non-malignant tumors are also very rare, and are of mere
pathological interest.
Cysts. The occurrence of true cysts in the myocardium is doubt-
ful (Quain), and hydatids, hæmatomata, etc., are of purely speculative
interest from a pathological point of view, as they have never been
diagnosticated during life.
RUPTURE OF THE HEART.
Rupture of the heart may occur from an injury of any kind, as a
blow or a fall, or from a wound, but it may result also in hearts pre-
viously affected, as by fatty degeneration, abscess, etc. It never occurs
spontaneously when the heart is healthy, but a predisposing cause
would be found in a thin or atrophied condition of the heart's walls,
or from softening.
Out of one hundred cases reported by one author, seventy-seven
were found to have undergone fatty degeneration, and to show the
influence of age; of these one hundred, sixty-three were above sixty
years old. An exciting cause may be some great mental or physical
effort.
The left ventricle most often is the seat of rupture, and then in the
apex. After this follow the right ventricle, right auricle, and left
auricle.
The torn part presents different characters in different cases. Some-
times the rupture may be complete, sometimes incomplete; when
complete, the hole is so small as barely to admit a probe, or is as
much as an inch in length, and jagged, as if one layer of fibres had
given way after another. A partial tear may occur, resulting afterwards
in complete rupture, but it is not easily decided whether the rupture
took place from within outwards or from without inwards, or during
464
A SYSTEM OF MEDICINE.
systole or diastole; however, the probabilities are that rupture is caused
by centripetal pressure during systole.
Incomplete rupture may be confined to the inner surface, or it may
occur in the substance of the walls, and any irregularity depends on
whether the rent is across the fibres or longitudinally with them; when
the rupture occurs in an abscess, it is rather a perforation than a rent.
The pericardium generally contains an effusion of blood, surrounding
the heart with clot and serum, as much as thirty ounces in one case.
Rupture is doubtless the result of a strain upon the muscular walls,
but in cases there may be softening with thinning of surface on the
internal side (chiefly the left ventricle), which gradually insinuates
itself between the muscular walls till it results in sudden rupture or
in perforation.
The symptoms are those of collapse, where death is not immediate,
coldness, small, irregular pulse, fainting, pallor, perhaps vomiting,
breathlessness, palpitation, and generally intense suffering. The
greatest physical signs are increased lateral dulness, from the dis-
tended condition of the pericardium, dull, muffled sounds, or none at
all, and diminished impulse.
The termination is certain death, although, according to the circum-
stances of the lesion, it may result immediately or not for several days.
The rupture may be partially closed by a clot, if the effusion is great,
owing to return pressure offered by the pericardial walls.
It is possible that rupture, partial or even complete, may happen,
and no knowledge ever be gained of it, for there are many recorded
instances where the heart has been wounded, complete recovery fol-
lowing; and there are at times found conditions on the heart-walls
which might indicate a previous lesion, with no evil consequences
beyond the scar.
E. NEUROSES OF THE HEART.
BY E. M. HALE, M.D.
ANGINA PECTORIS.
Synonyms.-Breast-pang, Syncope anginosa; French, Angine de
Poitrine; German, Brustbrauene.
Definition.—The name angina pectoris (from arxw, I strangle—
pectus, the breast, a strangled feeling of the breast) hardly warrants
the attempt at an exact definition, apart from the ideas which may be
derived from the picture of the symptoms, for it is not a disease in
the strict sense of the word; it has no accurate pathology, no localized
lesion, and even the very symptoms have such broad limits that they
are often the object of dispute. Its character has elements of func-
DISEASES OF THE ORGANS OF CIRCULATION.
465
tional, organic, and especially of nervous irregularities, and the highest
authorities can exhibit nothing more than a few isolated facts in favor
of one theory or another. Gairdner (Reynolds's System of Medicine) says
merely, "this group of symptoms." Perhaps the most concise defini-
tion, and the one expressing the tendency of modern views, is furnished
by Quain (Dictionary of Medicine): "An affection of the chest, charac-
terized by severe pain, faintness and anxiety, occurring in paroxysms;
connected with disorders of the pneumogastric and sympathetic nerves,
and their branches; and frequently associated with organic disease of
the heart.
History. The history of angina pectoris presents many interesting
points to the student, especially him of homoeopathy, for it shows
what a vast amount of literature may be written on one subject, and
of how little practical value the struggle among the pathologists is
when we see them confining all their attention to the cause of a group
of symptoms, omitting, in the dispute, the chief importance of the
symptoms themselves as a guide to what may result in a cure or, at
least, in an amelioration.
The first man to make an especial study of these symptoms, and the
one to whom we owe the use of the name, is Heberden, who, in 1796,
treated of this affection under the title of "De dolore pectoris " in his
Commentaries, though he had previously described it, his first commu-
nication on the subject (to the College of Physicians) being in 1768.
From that date to the present, the affection has enlisted the attention
of such men as Dr. Parry, Dr. Latham, M. Trousseau, and many
others, each advocating his own theory, but seldom advancing much
our knowledge, excepting through individual cases, till we come to
Dr. R. Quain, who, perhaps, sums up the result of modern investiga-
tion, leaving its pathology still very vague and indefinite. Another
interesting feature in the history of angina pectoris is the array of cele-
brated names whose cases are cited to illustrate the peculiar symp-
toms. Seneca, Lord Clarendon, Dr. John Hunter, Dr. Chalmers, Dr.
Arnold (of Rugby), are said to have been sufferers, and from the sen-
sations described by them, and others, we may pick out the few symp-
toms necessary to diagnose angina pectoris, if that name must be used
of some affection which presents us nothing objective as a guide.
Causes. These are either predisposing or exciting. Among the
former should be noted the fact that a predisposition to angina pectoris
may be inherited; that is, a patient may have handed down to him a
temperament which is nervous, susceptible to impressions, and char-
acterized by a highly developed condition of " the nervous element, as-
sociated with certain habits of life, sedentary employment, high living,
etc.," predisposing to such attacks.
The advantage of sex seems to be on the side of women, for they are
seldom the sufferers from this disorder, most all cases on record having
VOL. I.-30
466
A SYSTEM OF MEDICINE.
been in men; the age of a person, if not a predisposing cause, is cer-
tainly a factor in the liabilities, for persons advanced in years, of fifty,
or more, more often complain; cases in young persons are rare. Quain
says, the peculiar diathesis in which lithic acid predominates in the
system "" that which gives rise to neuralgia of various parts," is more
open to attacks of angina pectoris.
Of exciting causes may be mentioned: disease of the tissues of the
nerves themselves, or which may have a direct mechanical effect,
such as the pressure of a tumor or of an aneurism. Organic disease
of the heart is a great exciting factor, and many have tried to prove
that angina pectoris is always traceable to such a lesion. The mental
condition has a great influence, as undue excitement or great anger, a
celebrated instance of the latter being that of John Hunter, who died
suddenly after a passionate dispute in St. George's Hospital. It has
been noticed that attacks are more frequent in the open air, when it is
cold, and when there is a strong wind blowing in the face; exertion,
too, seems to act as an exciting cause, though this is, by no means, the
rule, for often the attack comes on during sleep, when lying down, and
when in a state of perfect quiet. A low condition of blood, as in ma-
laria, or such agents as tobacco. Also, irritation of the nerves, as of
the branches of the fifth, by means of the pneumogastric and sympa-
thetic. Trousseau tried to connect angina pectoris with epilepsy, even
called them identical, but though it is true that epileptic patients often
have such attacks, yet, on this theory there is no explanation for the
symptoms occurring in those to whom the suspicion of epilepsy has
never been attached.
If we examine the pathology of angina pectoris we are likely to be
utterly bewildered. I would refer for a minute study of this question.
to the same article in Quain's Dictionary, in which he enters carefully
and exhaustively into the anatomy of the nerves distributed to the
heart, and of those in connection with them. But the affection in
general is, undoubtedly, a form of neuralgia; the character of the pain
proves this. It has been ascribed to spasm, but a spasm of the heart,
lasting as long as an ordinary paroxysm of angina, would destroy life;
besides, the heart's action is seldom, if ever, arrested.
The pathological relations of angina are interesting. Flint says, "it
involves, in a large proportion of cases, the existence of some organic
affection of the heart and aorta," but, he adds, "the lesions found do
not agree invariably in any appreciable morbid alterations." Valvular
lesions may be present or absent. Calcification of the coronary arte-
ries is sometimes present; here, again, pathologists have tried to estab-
lish a necessary connection, but without sufficient proof, for changes
in these arteries have been noticed without the occurrence of symptoms
of angina. The converse is also true. Symptoms of angina have ex-
isted without visible alteration in the coronary arteries as demonstrated
DISEASES OF THE ORGANS OF CIRCULATION.
467
by post-mortem examination. Fatty degeneration has been observed,
and in Reynolds's System of Medicine it is half hinted that later micro-
scopical investigation can nearly always discover some progress towards
fatty degeneration which earlier investigators might have easily over-
looked.
It has been asserted that a weakened heart is essential to this dis-
order, but this theory is disputed by both Flint and Jones, though
somewhat supported by Gairdner, who adds, "I am able, from personal
experience, to say that no organic disease has appeared to me more
frequently to assume the symptomatic character of angina than aneu-
rism; and I am also prepared to state, as the general result of inquiries
extending over many years, and particularly directed to this subject,
that even small aneurisms arising very near the heart, and especially
such as project into the pericardium, or compress, in any degree, the
base of the heart itself, are much more apt to give rise to angina-like
symptoms than much larger tumors in more remote positions." "The
attention of physicians in cases of supposed angina pectoris should
therefore always be very minutely directed to the state of the arterial
system as a whole, and more especially to any evidences that may
exist of irregularities in the sound or impulses of the arteries near the
heart, or of the aorta near its ascending portion."
While it is not believed that a weak heart is a necessary condition, it
is more than probable that a condition is often present which is similar
to myalgia elsewhere in the body; in other words, cardiac myalgia may
simulate, or coexist with, angina.
Collecting then our knowledge on the subject, we may sum up by
saying that the symptoms of angina pectoris compose a neurosis of the
heart which may result from uncomplicated nervous affection, or
which may arise from complication with organic disease of the heart
or its closely connected blood vessels.
The post-mortem appearances are of too contradictory a character
to serve as a guide; the heart may be filled with blood or it may be
empty; there may be severe organic lesion, or none worthy of note.
Symptomatology. The affection is characterized by paroxysms
of intense pain, emanating from the region of the heart, and extending
in various directions, often into the left shoulder and down the arm,
accompanied by indescribable anguish, a sense of suffocation, and a
feeling of impending death. "A sense of dissolution, not a fear of it."
The pain radiates into both sides of the chest, into the back, upper
extremities, generally the left, but not always, and sometimes extends
into the lower extremities. The pain in the upper extremity does not
always extend into the hand, sometimes it ends at the shoulder, at
other times at the elbow, and the pain is occasionally felt only in the
forearm. It commonly seems to follow the course of the nerves, and
is felt all over the affected extremity, even to the ends of the fingers.
468
A SYSTEM OF MEDICINE.
The pain is attended by a feeling of numbness, or as if the limb
were paralyzed; a rare symptom is pain and numbness in the testicles.
Hyperæsthesia, or tenderness, where the pain is felt, has been ob-
served.
This is one of the affections which is purely paroxysmal, a strong
proof of its immediate connection with the nervous forces and centres.
The patient is seized suddenly, often during motion, as walking up
hill, or against a strong wind, or in turning in bed.
From the first instant of attack, all motion seems impossible. The
patient seizes hold of some firm support, or fixes himself in some way
immovable, until the paroxysm passes off.
Besides the pain, the feeling of suffocation alarms the patient, and
he feels as if death were imminent. Dyspnoea is not always present,
but the breathing is often suspended for an instant, or restrained by
an act of the will, for fear of increasing the pain, but the ability to
expand the chest and to breathe regularly is not impaired, hence a
symptom of true orthopnoea. Speaking is often impossible or difficult,
as it seems to aggravate the pain.
Palpitation is often present; the action of the heart in some cases is
intermitting and irregular; the pulse strong or feeble, and sometimes
very slow. The countenance is pale, and expresses terror, anxiety, and
distress, a death-like complexion and haggard features suddenly tak-
ing the place of an appearance of health. Lividity is sometimes ob-
served. The surface is cold and bathed in sweat, which is cold and
clammy. The faculties of the mind remain unaffected, or nearly so;
after an attack a sense of prostration is present, and, as after other
nervous attacks and spasms of the heart, there is a free secretion of
pale, watery, limpid urine.
The paroxysms differ in frequency of occurrence, duration, and
severity; and though generally coming unannounced, may be pre-
ceded by "symptoms of nervous irritation in the left side of the face
and head, as well as down the arm."
A special sensation in the chest has been sometimes noticed, where
"it seemed to be bulged out in a convex prominence, which suddenly
terminated in the lower end of the sternum in a sharp depression."
This sensation of irregularity about the chest is quite common.
The paroxysms may occur every few hours, days or weeks, but
years may elapse between them; sometimes very mild at first, they
may increase in severity, or may be very severe at the first attack.
They may often subside as suddenly as they commenced, or they may
disappear gradually.
It is an erroneous idea that they occur only after some physical or
mental excitement, for the attacks often come on at night during
sleep.
I have known persons who were thus affected rendered so fearful of
DISEASES OF THE ORGANS OF CIRCULATION.
469
going to sleep as to make life almost insupportable; in one case a fear-
ful dream seemed to the patient to be the exciting cause.
While death rarely occurs during the first attack, the disease is
rendered chronic, and finally terminates fatally, although the death
is modified by the cardiac or other lesions which usually accompany
these symptoms.
Diagnosis. The diagnosis is made from the symptoms, the most
prominent of which, as has been stated, are great pain; the sense (as
distinguished from fear) of sudden death; dread of being moved; and
unwillingness to breathe, with ability to do so, orthopnoea. Careful
attention should be paid to a thorough physical examination.
Prognosis. The prognosis depends largely upon the condition of
the heart. If that organ or the aorta be in a state of structural dis-
ease, the prognosis is far more unfavorable than if the disorder is purely
functional in character. If organic disease is present, we cannot as-
sure the patient of exemption from the recurrence of the attacks, while
if not connected with lesions, years may elapse before another par-
oxysm occurs. Paroxysms of angina pectoris sometimes cause sudden
death. In such instances "the action of the heart is arrested by a
morbid agency, affecting it through the pneumogastric nerves, in the
manner in which irritation of these nerves, or the electrical current,
produces this effect in experimental observation." (Flint.)
The danger is in proportion as the action of the heart is feeble, irregular
or retarded during the paroxysm. But if the action of the heart be but
little or not at all disturbed, sudden death is not to be feared. Organic
disease, rather than functional, suggests a sudden fatal termination.
Even if organic disease is present, judicious homoeopathic treatment
often cures, and, as a rule, is greatly successful if the affection is purely
functional or neuralgic.
Treatment.—In the treatment of angina pectoris we cannot be
guided by pathological notions. If we know organic disease to be
present in the patient, it will not guide us in prescribing during the
attack, although it may aid us in prescribing during the interval, for
the purpose of preventing future attacks.
There are two classes of medicines to be used: (1) Those which di-
minish the severity of the paroxysm, and which are capable of arrest-
ing it. (2) Those which will postpone or prevent the recurrence of
the attacks.
As to the treatment during the paroxysm, it is rarely the case that
a physician can get to his patient in time to be of much service. The
paroxysm is generally over, or the patient is dead, before the physi-
cian can reach him. Although I have treated many patients for the
disease, I have never seen but two in the paroxysm.
Amyl nitrite.-The most important remedy known for the immediate relief of
the paroxysm is Nitrite of amyl. This drug was first recommended by Dr. B. W.
470
A SYSTEM OF MEDICINE.
Richardson, and successfully carried out on a basis of careful clinical and experimental
observation in angina pectoris by Dr. Lauder Brunton. The theory upon which
Amyl was recommended, was that it relieved the spasmodic tension in the arterioles,
not only of the heart, but of the system generally.
In typical cases of angina the proofs are all on the side of this theory, namely:
during the paroxysm there exists a vaso-motor spasm not only of the arteries of
the heart, but of all the arterioles of the body. When Amyl is inhaled by a healthy
person there occurs, in a few seconds, a quickened circulation, tumultuous action of
the heart, quick respiration, the pulse will run up from 70 to 140, the face and whole
body will become red and flushed, and the pulsations of the heart will be felt in the
neck, head, and other parts.
e., cold-
The indications for its use are said to be this condition of vaso-motor spasm,
ness of the body, low pulse, agonizing pain in the heart and down the left arm, or-
thopnoea, etc. From two to five drops on cotton, or on a handkerchief, or even from an
open vial, generally gives relief in a few seconds, and shortens the attack, "strangling
it almost in its birth." Its inhalation should be suspended as soon as the effects of the
drug have fully appeared and the pain is arrested. Patients on whom it acts favor-
ably, should carry the drug about their person, either in vials previously filled with
absorbent cotton, or in the form of pearls de Amyl, small glass globes each containing
5 drops, which can be broken in the hand, or on a handkerchief, when needed.
This
There are, however, some curious discrepancies about the value and indications of
Amyl. Dr. Madden, who cured himself of angina by the continued use of Amyl,
thought it at first contra-indicated in his case, because his face was flushed during the
paroxysm. But, all other means failing, he resorted to it with signal success.
perhaps would show that the vaso-motor spasm may have been confined to the coro-
nary arteries. Dr. Madden noted the following effects during its inhalation: "Bron-
chial irritation causing cough, quickened circulation, sense of great fulness in the
temples and burning in the ears, violent commotion in the chest, tumultuous action of
the heart, quick respiration. The angina pain died out first in the chest, next in the
left upper arm, last of all in the wrist where it is usually very severe. When the pain
had ceased, there was generally for some time a strong involuntary tendency to sus-
pension of breathing, each prolonged pause being followed by a very deep inspiration."
In cases, not of typical angina, Amyl does not act so favorably. In one case of
"aortic insufficiency," and one of "aneurism of the first part of the aorta, pressing on
the right ventricle and pulmonary artery," the Amyl aggravated the symptoms, pro-
ducing alarming collapse, without any of its usual effects of flushing, etc. However,
it is a remedy of such value that we cannot dispense with it.
Glonoine, or Nitro-glycerin, is a drug which possesses powers almost identical
with Amyl. The chief difference appears to be that, while the effects of Amyl are
manifested in three to five seconds, and last not over fifteen minutes, those of Glonoine
are manifested in about three or five minutes, and often last five or six hours. The
symptoms of both, when they appear, are closely similar. In angina pectoris Glo-
noine has been used successfully. Dr. Lauder Brunton, in a paper contributed to the
St. Bartholomew Hospital Reports, 1876, says it is valuable in almost all heart dis-
eases, and "particularly in angina pectoris," also in weak, dilated and fatty hearts.
Professor Grabowski lately introduced it into the Krakauer Clinic, and reports that
"in angina pectoris its effects were simply marvellous, and the efficient action of the
drug could not be compared with that of any other known remedy." He uses a 1-per
cent. solution, in doses of five or six drops.
Professor McCall Anderson, of Glasgow University, says: "My experience, so far,
of the comparative merits of Nitro-glycerin and Nitrite of Amyl is that, while the
former acts more slowly, it seems to be more permanently beneficial." He reports a
case of angina-like pain when walking, referred to the region of the stomach. Ten
drops of a 1 per cent. solution (1° dil.), three times a day, effected a cure. When the
pain was on, a dose of 10 drops would arrest it.
In a late number of the Therapeutic Gazette, Dr. Farquar, of Zanesville, Ohio, reports
a case of angina pectoris, the paroxysms coming on regularly at night, between 2 and
6 o'clock. The attacks were typical, and the pain violent and excruciating. He cured
this case with Glonoine in doses of th of a grain, three times a day, in the form of
pills. They caused, however, several pathogenetic symptoms, namely: loss of vision,
pain and fulness in the head, weakness in the lower limbs, and extreme susceptibility to
noise.
25
Dr. Hering introduced this remedy in 1874, and gave us an extensive pathogenesis,
but I cannot find any record of its use in angina, except by Kafka, who prescribes it
in connection with Aurum, guided by the "congestion of the head," which we know
DISEASES OF THE ORGANS OF CIRCULATION.
471
does not occur, except in some rare forms of angina. The following symptoms of Glo-
noine, relating to the chest and heart, give a good picture of some cases of angina:
Dyspnoea, oppression of the chest: pain in chest, like tension, with frequent inclina-
tion to deep respiration; contraction of the chest, as if chains were being placed around
it, and tightened more and more; constriction and oppression of the chest, with per-
ceptible palpitation; constriction of the chest, as if it were screwed together; sharp
stitches in the region of the heart; great anxiety in the region of the heart; shocks in
the heart, with pricking pains in the hands and arms; when stooping, stitching pains
in the heart, so violent that he feared to bend forward." In some, the face was hot
and flushed; in others, pale and cold. Like Amyl, it sometimes causes collapse. I
imagine that Glonoine can cause a kind of angina by its primary action, and another
variety by its secondary action. This double action will be a guide to us in the selec-
tion of the dose. Should we find cases, like Dr. Madden, with "flushed face," etc., the
indication would be to give the 3d dil., or higher, while in typical cases, with complete
arterial vaso-motor spasm, the 1° dilution would be indicated, frequently during the
paroxysm, and three or four times a day during the intermissions, keeping just within
its pathogenetic action.
The use of Chloroform was once highly recommended, and its use has
often been of signal service in arresting the paroxysm. But the para-
lyzing influence of this anæsthetic on the cardiac muscle has led to its
virtual dismissal from the list of remedies. If used at all, it should be
mixed with Amyl nitrite (5 gtt. to 3i) and given cautiously. Ether
is much safer, and has often been used successfully.
When the paroxysm comes on only at night, and the pulse is habitu-
ally quick and weak, the old recommendation of Heberden, to give,
on going to bed, a dose of Opium (30 drops of McMunn's Elixir with
a teaspoonful of Aromatic Spirits of Ammonia) may be resorted to,
provided, the best selected remedies of our school have failed to prevent
the paroxysm. But if Opium is given, care must be taken that the
patient is free from uræmia, bronchial or pulmonary congestion or
œdema, or from fatty degeneration of the heart.
Professor Gairdner (Reynolds's System of Medicine) says of the treat-
ment during the paroxysm: "In my own experience no remedial
agencies have appeared more powerful than warm pediluvia with
mustard, and fomentations at the same time to the arms and thorax,
as hot as they can be borne. With these, and with Ether and other
diffusible stimulants, I have been able to dispense with the use of
large opiates in doubtful cases, or when they seemed to be contra-in-
dicated." Chloral hydrate is open to the same objections as Chloroform,
but there are on record some extraordinary cases where this drug, in
massive doses (3ii to 3iii), has been singularly efficacious; I cannot,
however, recommend its use.
The electric and galvanic current has been recommended, but no
reliable clinical experience has yet been reported.
One of the chief duties of the physician who is present during a
paroxysm is to exert a powerful moral influence on the patient and
his friends in attendance. He should assure the patient positively
that he will not die, for this will aid in dissipating the deadly fear
which often precipitates the patient's death. Keep the patient ab-
solutely quiet, and the attendants busy, but free from excitement.
472
A SYSTEM OF MEDICINE.
We now come to the radical or inter-paroxysmal treatment. This will
be guided by the ascertained pathological condition of the heart, if any
exists or can be discovered. If fatty degeneration, valvular disease or
aneurism exist, they should be treated with properly selected reme-
dies. If the disorder be typical or vaso-motor, the remedies must be
selected in accordance with the law of similia.
Generally speaking, tranquillity, both of body and mind, especially
the suspension of all occupations, or even amusements, that tend to
överstrain the heart or hurry the breathing; very moderate daily ex-
ercise on level ground, and only to such an extent as is necessary for
preserving the bodily tone or for good digestion; the avoidance of all
manner of food tending to flatulence, and the regular but strictly
moderate evacuation of the bowels, either spontaneously or by the
mildest laxatives, are measures of hygiene so obviously suggested by
simple prudence as to require hardly more than a passing allusion.
It is not by any means certainly ascertained whether the subjects of
angina ought to use alcoholic stimulants in any measure habitually,
or to reserve them for the critical period of the attack. I incline to
the latter opinion. Venereal excitement has probably in all cases an
unfavorable influence.
The use of tobacco in great excess has been specially investigated as
a cause of angina by M. Beau; but although I have frequently ob-
served palpitation and intermission in the heart's action in smokers, it
has not occurred to me to observe true angina thus produced. It will
be obviously right, however, to discountenance any indulgence of this
kind which is even doubtful as to its effects upon the heart's action.
If the patient is decidedly gouty or rheumatic, and the urine shows
persistently, or even frequently, a tendency to deposit lithic acid crys-
tals, and acid dyspepsia is present, it will be well to send him to some
alkaline springs of this country or Europe-and have him drink the
water regularly, and in proper quantities, until the acid diathesis is
changed. If a visit to springs is not convenient, the Citrates or Ben-
zoates of Potassa and Lithia should be prescribed for the same pur-
pose.
Arsenic of all medicines appears to have the widest reputation for the radical
treatment of angina, especially when there are no structural changes, unless we except
fatty degeneration, and the disease is neuralgic in character. It is further indicated
if there is some impoverishment of the blood; if the neurosis is hereditary, or due to
marked malaria. The homeopathic indications for Arsenic are: "he can only breathe
very gently, with the chest stooping forward; the least motion causes complete loss of
breath; oppression and stitches in the præcordial region, with anxiety and fainting;
arrest of breathing when getting out of bed, or change of position in bed, or walking
against the wind. Other symptoms indicating Arsenic in angina are numerous, and
will be found in its pathogenesis. Favorable results have been obtained from daily
doses of the 30th, or of the lower attenuations three or four times daily.
Arsenic has been used successfully by the allopathic school, and Dr. Anstie has
prominently recommended it in the form of Fowler's solution, beginning with three
minims, and gradually increasing the dose up to ten minims three times a day. He
complains that some neurotic cases cannot tolerate such doses, and on that account it
DISEASES OF THE ORGANS OF CIRCULATION.
473
has to be suspended." Had he had the slightest glimmering of the truth of the law of
similia he would have taken this intolerance as an indication that it was decidedly indi-
cated, and had he tried thero of a drop, persistently, his success would have been
more brilliant. In decidedly malarial cases the Arseniate of Quinia (Chin. ars.) will be
found very efficacious.
Digitalis comes next in importance. When this drug is given for a long time
in small doses, or in massive doses at short intervals, certain violent symptoms, once
called "cumulative effects," occur. They arise from a tetanic contraction of the heart,
with something like spasm of the cardiac and general arterioles, thus closely simulating
certain cases of typical angina pectoris.
It is symptomatically indicated when there is present the abnormal action, absent,
small, irregular, or intermittent or slow, pulse-with great anxiety and oppression of
the chest, with tendency to syncope and vertigo, with anguish and pain under the
sternum or in the epigastrium-with pain down the left arm. It is indicated also when
there is present valvular disease of the heart, or dilatation. I advise the first decimal
dilution, or the corresponding trituration of the leaves, three to five drops, or grains,
three times a day during the intervals, or if the paroxysms occur often. Digitalin in the
third decimal trituration, one grain three times a day, is a very reliable form of ad-
ministration.
Cuprum is indicated in those rare cases in which the pulse is
very slow, either
during the paroxysms or habitually, and the spasmodic orthopnoea is prominent. When
it is difficult to differentiate between Arsenic and Cuprum, as is often the case, the
Cuprum arseniosum may be substituted.
Crotalus, Lachesis and Naja are indicated by their peculiar symptoms.
Aurum mur. has been advised by Kafka when there is "hyperæmia in con-
sequence of stagnation of blood in the heart;" a very faulty indication, yet a study of
the symptoms of gold will show it to be useful in certain cases in which Glonoine is
indicated during the attacks.
Cactus is certainly indicated in angina-like attacks by its "constriction-symp-
toms," both in neurotic cases and in those with valvular disease.
Cocoa has been successful in warding off certain angina-like attacks brought on
by mountain climbing or rapid walking.
Oxalic acid was found to be efficacious when all other remedies failed. Dr. P.
Dudley, who reports the case, gives these characteristic symptoms: Difficulty of breath-
ing; jerking inspiration, and sudden and forced expiration, as though the patient
made a sudden effort to relieve himself of intense pain by expelling the air from the
lungs. Oppression of the chest, especially towards the right side; pain on expiration;
sharp, darting, or lancinating pains in the heart and left lung; also in the anus; jerk-
ing pains like short stitches, confined to a small space, lasting for a few seconds.
Numbness and weakness in back and limbs; peculiar numbness of whole body,
approaching to palsy; coldness and complete loss of power of motion in the limbs.
Movement excites and aggravates pain; periodical remission for some hours or days.
Convallaria is often superior to Digitalis in this disease. The great dyspnoea
on the slightest exertion, intense pain in the heart, point both to vaso-motor spasm
and paresis of the pneumogastric. It is equally useful in cases complicated with val-
vular disease. Adonis and Casca will doubtless be found useful in this affection.
Strychnia has been used successfully in those cases due to spinal paresis. I have
cured several presenting all the symptoms of angina, in persons suffering from spinal
exhaustion. The dose was to grain, four times daily, continued for weeks or months.
I am satisfied there are cases closely simulating this disease which
are wholly due to hysteria, uterine and ovarian disease. In such cases
Cimicifuga, Asafoetida, Lilium, and other utero-ovarian remedies prove
useful. I have used in similar cases with brilliant results hypoder-
mic injections of Morphia, Codea, and Atropia, in minute quantities,
and their effects were permanent, no recurrence appearing after the
production of sound sleep.
474
A SYSTEM OF MEDICINE.
FUNCTIONAL DISORDER OF THE HEART.
BY E. M. HALE, M.D.
PALPITATION, IRRITABILITY, INTERMITTENCY, ETC.
Synonyms. French, Palpitation du Cœur; German, Herzklopfen.
Definition. By a functional disorder is meant any disturbed ac-
tion of the heart which arises through the nervous system, independent
of any inflammatory or organic conditions. Though these latter may
give rise to functional disorder, yet, in such cases the cause can easily
be ascertained, and they, not the nervous disturbance, are to be investi-
gated and treated.
It should be remembered also that this nervous influence over the
heart can be exerted in various ways; and the nervous system in con-
nection with the heart is so intricate that many diseases, of themselves
distinct in character, set up a disturbance in the heart.
Ætiology.—A distinction drawn by many modern authors fairly
explains this difference, though it may lack accuracy. These causes
are divided into mediate and immediate. A mediate or exciting cause of
functional disturbance or palpitation is one which acts by disarranging
the nervous economy at some distance from the centres, hence by
reflexion; among such may be classed many and various causes of ill
health, i. e., disorders of the stomach, dissipation and its results, dis-
tension of the stomach by gases, producing irritation of the pneumo-
gastric nerve, certain articles of diet, causing disturbance of the diges-
tive process. But of all such, this palpitation of the heart is merely a
symptom, and the treatment, when requiring to be other than mechani-
cal (a removing of the obstruction or irritation), should be sought chiefly
in the treatment of these diseases.
Fothergill (Medical Record, July 26th, 1884) draws particular attention
to functional disorder, palpitation, in connection with ovarian trouble;
he mentions many symptoms in relation to the heart, and says "the
cause of all these linked phenomena is an irritable ovary when hunted
down." Again, palpitation is often a marked symptom in women at
the menopause when all the functions are more or less disturbed; and
unless the physician in these cases makes a careful diagnosis, his point
of attack in treatment is apt to be wrongly chosen. In mediate or pre-
disposing causes I make a subdivision again. Among these I like to
class such general derangements as anæmia; such deteriorations of the
blood as occur in gout (where lithic acid is said to play a prominent
part), scurvy, chlorosis, or hyperæmia; too great muscular exertion,
active exercise, which also excites palpitation; bodily exhaustion, vene-
real excesses, or a bad condition of the general constitution.
Age seems to be important; so is sex; for palpitation oftener occurs
DISEASES OF THE ORGANS OF CIRCULATION.
475
in young people than in the old, in women than in men. Hysterical
patients and choreic persons are subject to palpitation.
The direct source of cardiac innervation is an interesting question,
both in its pathological and therapeutical relations.
Barthez (Traité de Therapeut., vol. i., p. 43, par Trousseau and Pidoux)
says, we must make a distinction between the radical and the acting
forces governing the heart. The former may be nearly exhausted,
while the latter are in full play; and, vice versa, the latter may be but
slightly manifested, while the former are powerful. Accordingly, as
radical forces there are: A motor apparatus, situated in the substance
of the heart itself (which has power of independent motion), rhyth-
mically-discharging motor ganglia; the pneumogastric, which has a
regulative movement on the heart; and branches from the spinal cord.
As an acting force, there is always the sympathetic, stimulation of
which accelerates the pulsations of the heart, assisted by branches
from the spinal cord. Now, a functional disturbance must act through
these nerves, either by reflex action or directly. The result is perhaps
the same,-"an over-stimulation of the excitability of the muscular
structure, induced by functional errors of these nerves; i.e., the cardiac
ganglia, the vagus, or of those nerves which, proceeding from the car-
diac ganglia of the great sympathetic, supply the heart." Of the causes
of those reflex disturbances I have already disposed, as mediate and
indirect. I come now to speak of true neuroses, disordered action
due to direct or immediate causes, traceable to the nerves themselves.
These causes may be separated into two classes: (1) Nervous excite-
ment of the most varied kind, as joy, hope, surprise, fear, terror, and
profound mental emotion or shock; even home-sickness may excite
palpitation. And (2) nervous affection due to the use of stimulants,
like tea, coffee, tobacco, alcohol, or to the existence of gout, if we accept
the lithic acid theory.
The various ways in which these functional disturbances may mani-
fest themselves can best be understood by a close study of the patho-
genesis and symptomatology of the drugs employed in treatment, but
the following irregularities in the heart's action may serve as keynotes.
First, and most common, is palpitation; the heart is much accelerated
in beating, with halts at intervals as if it were going to stop; again,
there may be a continuous tumultuous beating, with occasional parox-
ysms of true palpitation. The heart may become irritable from too
great demand made upon it, or from a lack of rest, from over-straining
of sympathies, or from excessive work. Then there is intermittency
and irregularity. At times we find a heart abnormally slow in action,
due sometimes to depressing disturbances; sometimes, too, a congenital
weakness. Or, if not abnormally slow, the heart may go to the other
extreme, suddenly beating very rapidly, leading to the supposition that
the cardiac muscles are in a state resembling tetanus. And, as is fre-
476
A SYSTEM OF MEDICINE.
quently the case, the heart may act as if exhausted, like any other
over-worked machine.
Diagnosis. In declaring a diagnosis of functional disorder the
physician should be careful to assure himself that no organic lesion is.
present, and that there is no temporary or chronic inflammation, for
both these causes may originate functional disturbances which, under
such circumstances, do not belong to the neuroses.
Physical exploration is accordingly valuable, in showing the absence
of the signs of organic or inflammatory affections, and this information
is as valuable as if it included positive signs of true neurosis. If the
heart is not enlarged, the disorder is quite sure to be functional; yet,
if it is enlarged, we cannot affirm that the disorder is not functional.
Percussion settles the question of possible enlargement.
Palpation enables us to ascertain the force of the heart's action,
whether due to alterations in function or in structure. We find increased
and disturbed action in the former, augmented power in the latter. In
functional disturbances, the apex-beat is in its normal position.
Auscultation is important in two ways: First, by showing the absence
of abnormal sounds indicating valvular lesions; second, showing that
the natural sounds preserve their essential characters and normal re-
lation to each other. Functional disturbance is not often accompanied
by distinct "murmurs." It must be borne in mind that all normal
heart-sounds are intensified by the increased action present in func-
tional disorder, and if they are not changed, but merely intensified,
we may know that functional disorder only exists. When this physi-
cal diagnosis is made, and organic lesion doubted or denied, various
secondary considerations pointing one way or the other must receive.
our attention. Age for example, functional disorder appearing before
middle age of life. Sex; women are more subject than men to func-
tional disorder. The reverse is true with organic disease; hence these
factors go far towards deciding the point. In functional disorder the
patient is anxious and fearful, in organic disease he is usually apa-
thetic, and the same disturbance in organic disease causes much less
than the same irregularity when functional. Exercise may not aggra-
vate the functional symptoms, sometimes it relieves them, while the
reverse obtains in organic disease. Organic disease commonly origi-
nates in acute rheumatism; if the patient has escaped that affection,
the probability points towards functional disturbances.
Prognosis. The prognosis in cases of uncomplicated functional
disorder is always favorable. The opinion that it may lead to organic
lesions has been disproved. We may safely assure our patients that
if a recovery does not occur, no organic disease need be apprehended.
Treatment. The treatment of functional disorders of the heart,
or cardiasthenia, which I consider a better term, may be divided into
palliative and radical. The palliative is to be adopted when the
DISEASES OF THE ORGANS OF CIRCULATION.
477
paroxysms are present; the radical, like the deep undercurrent of a
river, during the course of the disease, until the cause is removed.
Palpitation. The palpitation which occurs from excessive exer-
cise, as climbing hills and mountains, running, swimming, etc., does
not always subside during rest. It is often persistent, and many
chronic cases of nervous heart-trouble can be traced back to excessive
physical exertion. A few doses of Aconite or Coca will generally suffice
to prevent continued disturbance, if taken early enough.
Palpitation due to fright, yields to Aconite; from excessive joy, to
Coffea; from grief, to Ignatia; from general mental excitement, to
Scutellaria, Valerian, and Bromide of Camphor. For paroxysms of
irregular and tumultuous beating, with violent impulse, simulating true
hypertrophy, the remedies are Veratrum viride and Veratrum album.
When the paroxysms occur in plethoric subjects, the former is pre-
ferred; when in exhausted subjects, the latter. Other remedies are
Cactus, Convallaria, and Belladonna. When the disorder is charac-
terized by irregularity and intermittency, with feeble action, the chief
remedies are Digitalis, Convallaria, Adonis, Arsenicum, and diffusible.
stimulants, such as pure wine, beef-tea, aromatic ammonia, and
warmth to the extremities.
((
There is a kind of nervous disorder of the heart, termed by patients
tremor" and "trembling." This may, or may not, be detected by
auscultation or by the pulse. It may be a tremor too fine to be
detected by the ear, or to show its effect on the pulse. This symptom
is often caused by the excessive use of tobacco and tea. Many reme-
dies have this symptom, notably: Kalmia, Lilium, Natrum mur.,
Spigelia, Camphor, Sumbul, Digitalis. If these fail, try Bromide of
sodium in doses of 5 grains, every two hours..
Hysterical cardiac troubles are generally best relieved by Amber-
gris, Asafoetida, Camphor, Crocus, Ignatia, Sumbul, Valerian, and
Scutellaria.
The radical treatment of cardiasthenia must be prolonged and con-
tinuous. The remedies should be carefully studied out, not only on
the plan recommended by Hahnemann, but according to their organic
and tissue affinities.
Plethora should be removed by appropriate diet and exercise.
Small meals, composed nearly altogether of fatty food or lean meat,
no tea or coffee, no sugar or pastry, much exercise, Turkish baths, etc.,
are the principal means.
Adiposis is best treated by the same hygienic means, together with
the use of 10 grains Bromide of Ammonia, three times a day, or Fucus
vesiculosus, in doses of one drachm of the fluid extract, thrice daily.
Anæmia, by a rich, nitrogenous diet, life in the pure, open air, free
from malaria, and by the use of Ferrum, Cuprum, China, Helonias,
Ignatia, Nux, Calcarea, and the Hypophosphites. I have obtained
478
A SYSTEM OF MEDICINE.
the best success in idiopathic anæmia, associated with functional dis-
turbance of the heart, by the alternation of Ferrum and Digitalis,
Ferrum and Strychnia, or Ferrum and Arsenicum.
Ferro-cyanuret of iron has made some remarkable cures of anæmia
and chlorosis with great cardiac weakness. Iodide of iron, also, in
strumous subjects, has been found singularly successful.
Collinsonia, which I recommended in my Lectures on Diseases of the
Heart, has not been found as curative as the reports of Eclectic physi-
cians led us to expect, but I have found it useful in some cases arising
from suppressed hæmorrhoids and intestinal irritation.
Cardiac neuroses caused by uterine or ovarian irritation are best met
by the Bromides, in appreciable doses, especially if attended by profuse
menses and erotomania, sleeplessness, and general nervous erethism.
Massive doses will surely bring on all these conditions by their
secondary effects; but doses of 1 to 5 grains, three times daily, will
remove them. The Monobromide of Camphor must be used in
smaller doses, 1' to 3 trituration. If the neurosis or cardiac irritation
is from a gouty or rheumatic diathesis, the Bromide of Lithia in similar
doses is specific. Lilium tig., in my practice, has oftener proved of
service than any other.
Convallaria maj. (lily of the valley) stands next in order. It belongs
to the same botanical family, and its pathogenesy shows many uterine
and ovarian symptoms similar to the tiger-lily. No other cardiac
remedy has such a broad and potent sphere of action as this, and it
will prove one of our most powerful curative agents in a large propor-
tion of cardiac neuroses, whether reflex or idiopathic.
Lachesis, Naja, Apis, Conium, Platina, Cimicifuga, Viburnum op.,
Nux moschata, Sepia, and Pulsatilla will all be found indicated in
certain cases.
If dyspepsia or gastro-intestinal irritation is the cause, Nux vomica,
Bismuth, Lycopodium, Hydrastis, Euonymus, Iris, Pulsatilla, Podo-
phyllin, and Nitro-muriatic acid will be found indicated. In such
cases not medicines alone will cure, but we must see that the patient's
diet is corrected, and must assist his digestion by the approved use of
Pepsin and Pancreatin.
In a large number of instances of obstinate cardiac disturbances I
have found the colon loaded and distended by enormous quantities of
fæcal accumulations. Enemas of salt water, Ox-gall or Castor-oil
emulsions, will generally remove them, aided by abdominal massage.
But some cases resist these measures, as well as homoeopathic reme-
dies like Opium, Plumbum, Nux, or Aluminum. It is our duty in
such to empty the colon by laxatives; the most efficient I have found
to be McKesson & Robbin's or Warner's pills of " Aloin, Belladonna,
and Strychnia," or "Aloin and Ergotin." These will sweep out effectu-
ally the poisonous accumulation, and the obstinate cardiac irritation
DISEASES OF THE ORGANS OF CIRCULATION.
479
will leave as if by magic. Then, we can restore the paretic colon to its
normal function by appropriate remedies-Nux, Hydrastis, Ergot, or
Physostigma, and appropriate food.
Flatulence is a potent cause of cardiac disturbance. It will excite
the heart to violent palpitation, cause irregular and intermittent action,
and even syncope and dyspnoea from cardiac failure. The most
potent remedy I have used for this is Creosote, 13, a drop every twenty
minutes till the patient is relieved. Oleum cajuputi, Turpentine, and
Naphthaline are also efficient remedies. Lycopodium is of great
value. Pepsin is invaluable in indigestion from deficiency of gastric
juice. Nitro-muriatic acid (dilute), 5 drops before meals, and th
grain of Strychnia, after meals, is the best prescription for a radical
cure of flatulence.
1
Dr. Murchison (Lectures on Functional Disorders of the Liver) says
that hepatic troubles are a prolific cause of cardiac disturbance.
The intermittency which they cause is peculiar. It is worse on sit-
ting or lying down; better by motion. The same may be said of the
palpitation and the slow pulse due to such disorders. These facts I
have often verified. I have found that Euonymin, 1' to 3, is nearly
specific in such cases; Podophyllin, 2 to 6*, very useful; Chelidonium
and Carduus are often indicated; Nux vomica rarely.
CARDIASTHENIA.
I believe there is a true, idiopathic disease due to paresis of the
inter-cardiac ganglia. It is caused by strain or overwork of the heart.
The primal causes may be reflex, or spinal, or cerebral, but the condition
set up by these causes will often persist, from force of habit, long after
the reflex, and other, causes have ceased to be present. This condition.
can only be treated on the same principles on which we treat neuras-
thenia or cerebrasthenia, namely: absolute rest of the heart as much
as is possible (by mental and physical quiet), and the administration
of cardiac restoratives, with massage and such food as will lead to
increased innervation of the heart. Digitalis, Convallaria, Adonis,
Strychnia, Ignatia, Nux, Ferrym, and Phosphorus are the medicines.
Oleaginous, nitrogenous, and all blood-making foods are the agents for
increased nutrition.
This is the proper place to call attention to causes of cardiasthenia
of a purely emotional origin. I have fully treated of this subject in
the Appendix to the last edition of my work on the heart. But I will
here recapitulate certain facts relating to the nervous supply of the
heart.
(1.) The inter-cardiac supply. The heart is supplied with a number
of little, self-acting nerve-ganglia without relations to the brain, from
* "Lectures on Diseases of the Heart." 2d ed. Boericke & Tafel.
480
A SYSTEM OF MEDICINE.
which spring, under the influence of the blood, a certain number of
motor impulsions. These ganglia govern the usual normal action of
the cardiac apparatus.
(2.) The brain sends out to the heart two sets of nerves, the retarda-
tors (pneumogastric) and the accelerators. Excitation of the former
diminishes the frequency and augments the force of the heart's move-
ments. Excitation of the latter produces the opposite results, increas-
ing the number and lessening the force of the heart's contractions.
Now, when the emotional nature of man is normal and not exces-
sive in quality or quantity, no abnormal cardiac manifestations are
present. In races low in condition, ignorant, and uncivilized, the
emotional functions rarely excite the heart unduly, for only in the
highly civilized and refined do we find the general nervous system
abnormally sensitive to emotional influences.
In such races and nations as the latter, it is not strange that the
intense and varied emotions to which they are subjected should render
the heart hypersensitive, and finally reduce it to that condition aptly
called cardiasthenia. In such cases not only is the brain hyperæs-
thetic, but certain portions, or the whole, of the spinal cord usually
partake of the same condition.
The upper portion of the cord sends nerves to the pneumogastric,
and thereby influences the action and functions of the heart. Thus it
is that spinal hyperæsthesia complicates the trouble.
Death may ensue from cardiasthenia, for there will come a time
when the heart will die from the exhaustion of its sources of inner-
vation.
The treatment of cerebral cardiasthenia is more moral and emo-
tional than medicinal. By change of scene, of occupation, of mental
influences, we must modify and render more natural, and less sensitive,
the emotional centres. We have medicines, thanks to Hahnemann
and later observers, which may aid us in calming and strengthening
the cerebral functions. There will still remain the hypersensitive inter-
cardiac nerve-ganglia. Fortunately, we have now a large number of
remedies which have a similar influence over these. The task of
enumerating these remedies is too great to be attempted. Each case
must be studied as to its origin and its peculiar symptoms, and the
remedy selected according to the law of similia.
DISEASES OF THE ORGANS OF CIRCULATION.
481
F. DISEASES OF THE GREAT BLOOD VESSELS.
BY A. R. THOMAS, M.D.
DISEASES OF THE AORTA.
INFLAMMATION. AORTITIS.
Few organs of the body are more free from acute inflammation than
the aorta. Indeed, except as the walls of the vessels may occasionally
become involved in the inflammations of surrounding structures, the
condition scarcely ever exists. Chronic inflammation, however, is by no
means unusual, this condition being the initial process for most of the
structural changes to which the aorta, with other blood vessels, is liable.
Owing to the absence of capillary vessels in the inner coat of arte-
ries, the inflammatory process commences in the vascular layer beneath
the latter, extending, perhaps, to the middle and external coats, affect-
ing the inner coat only by modifying its nutritive, and thus favoring
degenerative, changes.
The causes of these inflammations may be various, but are not gen-
erally very apparent. Age, constitutional cachexia, etc., and occasion-
ally the breaking down of coagula formed within the vessel, may be
found more or less directly associated with this condition.
There are no reliable symptoms by which inflammation of the aorta
may be recognized during life.
ATHEROMA.
This degenerative process is one of the most frequent as well as im-
portant of the pathological conditions of the aorta. Resulting from a
preceding inflammatory condition of the walls of the vessels, it may,
by weakening the same, give rise to dilatation, aneurism, or rupture.
It affects most frequently the arch of the aorta, yet may involve the
whole vessel.
Atheroma usually commences in the deeper layers of the inner coat
of the aorta, involving the surface of the latter more by an extension.
of the inflammatory products (proliferated cell elements) into its sub-
stance. As these products increase in quantity, they cause a charac-
teristic thickening and swelling of the inner coat, these occurring in
patches rather than involving the whole surface. Fatty degeneration
of the involved structure may accompany or follow the process, or an
infiltration with calcareous matter may result, giving roughness with
brittleness to the inner coat.
While in the earlier stages of atheroma there may be a slight nar-
rowing of the calibre of the aorta from a thickening of its walls, later,
from a softening and a weakening of the same, dilatation is most cer-
tain to occur, possibly rupture or aneurism. If a section be made of
VOL. I.-31
482
A SYSTEM OF MEDICINE.
an atheromatous portion of the aorta, it may be found increased to
three or four times the normal thickness. It may be slightly softer
than the normal tissue of the artery, or it may be of a pulpy, or even
of a semi-fluid, consistency. When less softened, it may present a dis-
tinct laminated character. In rare cases the disease may attack, and be
confined to, the middle coats of the aorta. The condition of the atheroma
of the aorta may be readily recognized in post-mortem examinations
by patches of a whitish-yellow color, more generally confined to the arch
of the vessel, seated within or beneath the inner coat, varying in size.
and shape, slightly elevated, yet presenting a smooth surface, being
covered by a thin layer of the endothelium. When calcification has
taken place, although commencing in the deeper layers, this covering
may have disappeared, leaving rough surfaces of calcareous plates ex-
posed directly to the current of blood.
Etiology.-Age and certain constitutional conditions are believed
to be most important factors in the production of atheroma of the
aorta. Employment has its influence, as those engaged in laborious
occupations appear more subject to the disease than others; hence, it
is more common with men than with women. Old age and syphilitic
taint are believed to be most frequent predisposing causes, while rheu-
matism, alcoholism, gout and kidney-disease may all play a part.
Symptoms. These may be so obscure that extensive atheroma of
the aorta may exist while neither subjective nor objective symptoms
may be present. As dilatation comes on, however, and more especially
aneurism or embolism-secondary results of atheroma-symptoms
may arise leading to a recognition of the disease. Functional distur-
bances of the heart, angina, and various symptoms that would usually
be defined as "dyspeptic" may be present in the earlier stages, but they
can rarely be traced to this condition of the aorta as a cause. Later
in the progress of the disease, by careful auscultation of the heart, par-
ticularly while the action is a little accelerated by exercise, there may
be noticed, first, a slight indistinctness of the first sound; second,
moderate increase of the second sound; and third, a slight post-systolic
murmur along the course of the arch of the aorta.
At a still later period, indications of dilatation may be present, as pul-
sation and increased dulness over the arch of the aorta. When marked
calcareous degeneration has taken place, slight fremitus may, in some
cases, be detected in the same position. The subjective symptoms are
likely, at the same time, to be increased in severity and frequency.
Embolism may exhibit itself by sudden hemiplegia, hæmorrhage, or
gangrene of some part, or symptoms of aneurism appear, and death
suddenly result either from rupture of the vessel, embolism of the
brain, or from some trouble of the heart which is liable to attend athe-
oma of the aorta.
Treatment.-Aside from palliative measures, little can be done in
DISEASES OF THE ORGANS OF CIRCULATION.
483
the way of treatment of atheroma of the aorta. All the habits of the
patient should be most carefully regulated; excesses of all kinds,
whether physical, emotional, or dietetic, should be strictly avoided.
Stimulants are undoubtedly injurious when habitually employed, yet
may be useful in severe attacks of pain or of dyspnoea.
Among the homoeopathic remedies most likely to be indicated in
these cases may be mentioned Aconite, Arsenicum, Arnica, Cactus,
Digitalis, Gelsemium, Kalmia latifolia, Lachesis, Laurocerasus, Nux
moschata, Tarantula, Veratrum viride. The peculiar symptoms in each
case must be the guide for the selection of the remedy.
ANEURISM OF THE AORTA.
This constitutes one of the most formidable as well as most dreaded
diseases to which man is liable. Insidious in its approach, distress-
ingly painful in its character, liable at any moment to a fatal termina-
tion, the sufferer feels his life suspended, as it were, by the most feeble
thread, and with momentary liability to its sudden severance.
Definition.-Aneurism of the aorta consists in a dilatation of the
walls of the vessel in some part of its course with, possibly, rupture of
the same, and the formation of a tumor filled with blood. The follow-
ing varieties are recognized: 1st. Fusiform or Cylindric, in which the
dilatation is more or less general in its character, involving the whole
circumference of the vessel. This is sometimes termed simple dilata-
tion. 2d. Sacculated, when the dilatation is more local, and results in
the formation of a sac or pouch communicating with the cavity of the
vessel. 3d. Diffused or False Aneurism, when from a rupture of the coats.
of the vessel the blood becomes diffused into the surrounding tissues.
4th. Dissecting Aneurism, in which the inner and middle coats only give
way, and the blood is forced between the middle and outer coats, or
perhaps splits the middle coat into layers. In this form the blood
may work its way for a long distance from the point of rupture for the
whole length even of the aorta, and in some cases will again reënter
the vessel by another opening from the inner coat. 5th. Varicose or
Anastomosing Aneurism. In this variety there is established a direct
communication between the aneurismal tumor and one of the large
venous trunks, as the vena cava, or one of the innominata or subclavian
veins, or with the pulmonary artery.
In some rare instances a communication has been established with
one of the cavities of the heart. In all these cases the communication
is the result of contact and pressure of the growing tumor, with final
absorption of the intervening walls. Great disturbance of the circula-
tion and sudden death result from the establishment of such commu-
nications.
All portions of the aorta are not equally subject to this disease. Of
seven hundred and three cases collected by Sibson, four hundred and
484
A SYSTEM OF MEDICINE.
forty-nine were of the thoracic, and two hundred and fifty-four of the
abdominal, aorta. Of those connected with the thoracic portion of the
vessel, eighty-seven were of the first portion of the arch and intra-
pericardial; one hundred and ninety-three were of the ascending por-
tion and extra-pericardial; twenty-six were of the transverse portion;
seventy-two of the descending portion of the arch; and seventy-one
of the remaining portion of the thoracic aorta, making three hun-
dred and seventy-eight for the arch and seventy-one for the thoracic
aorta.
Etiology. The softening and weakening of the walls of the aorta
resulting from inflammatory action and atheromatous changes must be
looked upon as one of the most frequent primary causes of aneurism
of the aorta. The secondary or exciting causes will include everything
that may tend to increase the blood-pressure upon the already weak-
ened vessels. Prominent among these may be mentioned:
1st. Hypertrophy of the left ventricle, the increased power of the heart
driving the blood into the weakened vessels with greater force than
they are able to resist. On the other hand, weakened aortic walls
may become the cause of a hypertrophied left ventricle, the two con-
ditions thus acting and reacting upon each other.
2d. Strain, as induced by falls, blows or violent muscular efforts.
3d. Obstruction to a free circulation through the great vessels beyond
the aorta, as from constriction of the abdominal walls by tight belts, or
of the carotids and axillary by tightly fitting dress. It has been shown.
that soldiers in the British army are vastly more subject to aneurism
than civilians, owing, undoubtedly, to the fact that their tightly fitting
dress and heavy equipments, in all heavy marches or violent exercise,
tend to increase the blood-pressure within the aorta. Sailors, on the
other hand, though required to make frequent and violent exercise,
are more exempt from aneurism, the result, no doubt, of their more
loosely fitting dress.
4th. Mental Emotion, through its influence in exciting and disturbing
the action of the heart, rheumatism, gout, syphilis and intemperance,
may each also become a factor in the production of aneurism from
their power to induce disease of the heart and arteries.
Aneurism is a disease of middle life. It is rare before thirty, the
greater number of cases occurring between forty and sixty. Men are
much more liable to this disease than women, the difference depend-
ing, no doubt, mainly upon their more active lives.
Symptoms.-The subjective symptoms of aneurism will be found
to vary greatly, according to the manner of origin, seat, stage of de-
velopment, etc. If the result of some sudden, violent strain, as from
a fall or blow, or from lifting a heavy weight, the patient, previously
perhaps in good health, may experience a sudden pain in the chest,
of a more or less severe character, and followed in time by the usual
DISEASES OF THE ORGANS OF CIRCULATION.
485
symptoms of aneurism. In another case there may have been evidence
of impaired general health and, possibly, evidence of disease of the
aorta may have been detected, yet the symptoms of aneurism come on
very gradually and almost imperceptibly. During the progress of the
disease there may appear, more or less prominently, pain, dyspnœa,
cough, hoarseness, headache, with disordered vision and hæmorrhage.
cause.
The pain of aortic aneurism is usually of a burning or aching, wear-
ing character, and generally referred to the seat of the disease, although
it may radiate to distant points. The dyspnoea is frequently marked,
and is varied in its character according to the seat and nature of its
It may result from the presence of a tumor within the chest,
producing pressure on the bronchial tubes, or from obstructed circula-
tion through the lungs. Both pain and dyspnoea occur frequently in
paroxysms, varying according to excitement of the circulation. The
cough is frequently harassing, dry and paroxysmal. Laryngeal op-
pression and stridulous breathing may be induced by disturbance of
the recurrent branch of the pneumogastric, as this may be compressed,
stretched, or dragged from its position by the tumor when of the arch
of the aorta.
Aneurism of the abdominal aorta will usually be accompanied by
pain of an intermittent and paroxysmal character. It may radiate
from the seat of the trouble to different portions of the abdomen, back
or pelvis. As a result of pressure, there may be functional disturbance
of several organs, as jaundice from pressure on the common bile-duct;
vomiting from pressure on the pylorus; kidney derangement may also
result from pressure on the renal vessels, while displacement of the
heart or liver may result from the same cause. The upper portion of
the abdominal aorta is more frequently affected by aneurism. It is
rarely found as low as the origin of the renals.
The Objective Symptoms, as revealed by physical examination,
are equally characteristic. Inspection will show in many cases of
thoracic aneurism a swelling of the face and neck with turgescence of
the vessels, extending, perhaps, to the arms, and the result of pressure
upon the vena cava or other large venous trunks. As the tumor in-
creases to considerable size, a bulging of the chest walls may be noticed,
corresponding to the portion of the aorta involved; when to the right
of the sternum, and near the second intercostal space, aneurism of the
ascending portion of the arch will be indicated; when at the upper
arch of the sternum, the transverse portion. If to the left of the ster-
num, and in the second or third intercostal space, the descending arch
will be the involved portion, while a bulging to the left of the spinal
column behind, would indicate aneurism of the descending thoracic
aorta. As the tumor reaches considerable size, it will usually be of a
conical shape, with a shining, smooth surface, and may be seen to
pulsate synchronously with the action of the heart. Occasionally in
486
A SYSTEM OF MEDICINE.
aneurism of the aorta, there may be noticed an inequality of the pupils,
consisting of a contraction of the pupil on the side corresponding to
the seat of the aneurism, and, undoubtedly, attributable to pressure on
the sympathetic nerve.
Palpation will enable us to judge of the size of the tumor, of its
elasticity, and thus of the character of its contents, whether fluid blood
or fibrinous clots, of the character and force of the pulsation, of the
thickness of the walls, and so on.
Auscultation of aneurism of the aorta will usually reveal charac-
teristic sounds or murmurs. These will vary according to the location
and size of the tumor, nature of its contents, and so on. The sounds
will not only be found synchronous with those of the heart, but fre-
quently presenting a corresponding systolic and diastolic rhythm also.
The character of the murmur will present great variations. It may be
simply blowing, or rough, rasping, sawing or filing in its character.
It is generally low-pitched and short in duration; in some cases it
may be totally absent.
The physical signs of abdominal aneurism, as revealed by palpation,
are a smooth, elastic, pulsating tumor to the left of the middle line,
the pulsations being increased by pressure upon the aorta below.
The examination should be made with the patient on the back, with
the thighs flexed, to relax as much as possible the abdominal walls.
Percussion will be of less value in abdominal than in thoracic aneu-
rism, owing to the large mass of intestines, perhaps filled with gases,
covering the tumor. Auscultation will usually reveal a murmur, gen-
erally post-systolic, single and prolonged. The sound may be blowing,
buzzing, or even of a musical character, according to the nature and
condition of the contents of the sac; it is rarely heard in the vessels
below. In an erect position this murmur is usually absent, but rarely
so in the recumbent.
Diagnosis.—The difficulties in arriving at a diagnosis in aneurism
of the aorta will depend much upon its seat and stage of development.
In all cases we shall have to discriminate between aneurism and
tumors, thoracic or abdominal. These may occasionally so rest on
the aorta as to receive a pulsation from that vessel. This will not,
however, present the elastic or expansive character of the aneurism,
but be more of a lifting quality. Sounds or murmurs are generally
absent in the tumors, though we may have transmitted sounds from
the aorta. The result of pressure on veins may be similar in tumors
as in aneurism. In tumors, however, the swelling and oedema of the
face and arms is more persistent than in aneurism. From pressure on
the heart and lungs the subjective symptoms may be very similar.
The bulging of the chest walls will, however, establish the diagnosis
in thoracic aneurism, and the position of the tumor and the pulsation
with murmur in the abdominal. Aneurism of the innominata artery
DISEASES OF THE ORGANS OF CIRCULATION.
487
may be distinguished from that of the aorta by its position, high in
the chest, and more to the right of the sternum. Again, pressure on
the carotid or subclavian will diminish the pulsation in aneurism of
the innominata, but will not affect that of the aortic arch. Pulsations
in the epigastrium are not infrequently met, simulating aneurism,
which, however, may be transmitted from a dilated or hypertrophied
left ventricle.
An examination of the pulse in the two wrists may reveal differences
characteristic of aneurism. They may vary in size, or there may be
an apparent delay in the pulse on one side. The sphygmograph may
also, in some cases, be of value in diagnosticating aortic aneurism, the
systolic wave, as indicated by the tracings, being considerably pro-
longed.
Prognosis, Course, and Termination.-The prognosis of aneu-
rism of the aorta is always extremely unfavorable. Cases of cures
have been known, but they are extremely rare. The duration of the
disease varies from a few weeks to many years. Filling of the sac
with laminated fibrinous clots by producing pressure upon its walls,
may serve to retard its development, and thus delay a fatal termina-
tion, or even result in a cure. The usual progress of the disease, how-
ever, is for the tumor to become larger and larger, its walls in the same.
proportion attenuated and softened, the system becoming more re-
duced from pain, with loss of rest, death finally resulting either from
rupture of the sac with its attending hæmorrhage, or from gradual ex-
haustion. Rupture may take place into the pericardial cavity, into one
of the chambers of the heart, into the pulmonary artery, either vena
cava, the innominata vein, and rarely into the vena porta. Or, again,
the rupture may take place into the trachea or bronchial tubes, or into
the esophagus or stomach. In either of these cases, death will be
likely to be sudden. Hæmatemesis or hæmoptysis will follow where
the rupture is into the stomach or air-passages.
A gentleman of about sixty years, after a hearty dinner, was taken
with vomiting, first of blood and food, then of blood alone. The
vomiting of blood continued, and in less than an hour the man was
dead. A post-mortem examination revealed, first, a tumor in the
second intercostal space, to the right of the sternum, of the size of half
an orange, firm and immovable. This tumor proved to be an aneu-
rism of the ascending portion of the arch of the aorta, in which a spon-
taneous cure had taken place. It was known by the family to have
been present externally for fifteen years. The adjoining costal carti-
lages, with the border of the sternum, had been absorbed. Second, an
aneurism of the descending arch, which had ruptured into the œsoph-
agus. From this came the hæmatemesis and death.
Rupture occurring in a serous cavity into the mediastinum or upon
the surface of the body need not necessarily be immediately fatal.
488
A SYSTEM OF MEDICINE.
The adhesion of serous surfaces on the mass of dense clots may so
obstruct the flow as for a time to delay the fatal result.
Spontaneous cure of aneurism, when occurring, is always the result
of the formation of fibrinous clots lining the sac and arranged in
concentric layers. Becoming partially organized, they acquire suffi-
cient vitality to preserve their integrity, and by filling the sac and
preventing the entrance of blood into the same, effect virtually a cure
of the aneurism. It is the aim of the surgeon, in the treatment of
aneurism of arteries within his reach, to induce the same result by
the employment of pressure or ligatures.
The case last reported gave an instance of spontaneous cure by this
method. Another has come under the notice of the writer. A lady
of seventy-five years died from exhaustion and old age. She had
suffered from obscure symptoms in the left chest. A post-mortem
examination was held. On passing the hand behind the left lung, a
tumor was found of the size of the fist, and adherent to the lung and
surrounding tissues. On removal, the tumor proved to be an aneu-
rism of the middle portion of the thoracic aorta, firmly filled with
dense fibrinous matter, completely excluding the blood, and arresting
further development. It was judged that this condition had continued
for a long time.
Treatment.-The rational treatment of aneurism of the aorta in-
cludes not only the use of such remedies as may be found homoeo-
pathic to the symptoms present, but the use of such measures as may
tend to promote the coagulation of the blood in the sac, including
such palliative means as humanity and experience may dictate as
effective in relieving suffering in an almost hopelessly incurable dis-
ease. The treatment of aneurism of the aorta may be divided into:
1st, the homœopathic treatment; 2d, the physiological; 3d, the surgical; 4th,
the palliative.
Homœopathic Treatment. A great variety of remedies will be
found presenting the objective symptoms of aneurism of the aorta.
Great care will be required in making the selection. Prominent in
the list of remedies would stand: Aconite, Veratrum viride, Digitalis,
Gelsemium, and Laurocerasus, while a place may be found for Sul-
phur, Calcarea carbonica, Calcarea phosphorica, and several other
remedies.
The physiological treatment includes the employment of such
measures, other than surgical, as tend to favor the coagulation of blood
within the sac, as a cure can be hoped for only as that end is attained.
It is well known that a retarded circulation favors the coagulation of
the blood, hence complete rest in a recumbent position will not only
diminish the strain on the weakened vessel, but facilitate fibrinous.
deposits within the sac. The diet at the same time should be some-
what restricted in quantity, yet nutritious in quality. This course
DISEASES OF THE ORGANS OF CIRCULATION.
489
persevered in for six to eight weeks has been found quite successful
in securing a filling of the sac with coagula.
The influence of certain drugs in lessening the force of the circula-
tion, when given in doses to secure their physiological effects, should
lead to a consideration of their use in these cases, with the view of
securing their aid in favoring the coagulation of the blood. Among
the most important of these may be mentioned Aconite, Digitalis, and
Veratrum viride. To secure any advantage from their use, they must
be employed in full doses. The Iodide of potassium has also been
highly recommended, since it induces coagulation of the blood, al-
though some authors consider this effect due to the sedative action
of the drug upon the heart. It should be used in doses of from
fifteen to thirty grains, repeated every four to twenty-four hours. Dr.
Balfour, of Edinburgh, and others, have reported flattering results
from this treatment. Dr. Helmuth, of New York, however, has but
little to say in its favor, and my own experience with the drug has not
been encouraging.
The surgical treatment will include (a) application of ligatures.
This is available, however, in a few cases only. In some cases of
aneurism of the arch, involving the innominata, or other large branches,
by ligating the latter the circulation may be so changed in the arch as
to favor a filling of a portion of the vessels with clot, so as at least to
delay the progress of the disease, if not to effect a cure. In aneurism
of the abdominal aorta, the lower portion of that vessel has been tied,
but with such unfavorable results as to make the operation scarcely
advisable. (b) Compression in the treatment of aneurism of the ab-
dominal aorta offers the greatest encouragement for success. Inasmuch
as aneurism of the abdominal aorta is seldom found below its middle
portion, the vast majority occurring in its upper third, all the lower
portion of the vessel will be available for the application of pressure.
Resting, as it does, against the spinal column, to the left of its centre,
the abdominal walls-particularly in thin persons-will offer but little
impediment to bringing effective pressure upon this vessel. The aorta
terminating opposite the umbilicus, the pressure will be required at a
point about midway between that and the ensiform cartilage. Tour-
niquets, especially intended for this purpose, have been devised by
Lister, and others. They should be used under an anesthetic, after
the bowels have been emptied, and with such force as to completely
arrest the flow of blood through the vessel. The pressure should be
kept up for at least four hours. If the pulsations still continue after
four or six days, the instrument may again be applied, and the pres-
sure continued for six to eight hours. In many cases the pulsations.
have ceased after the first application, and in a few days the patient
has been considered well.
Where an aneurism of the aorta threatens to burst upon the surface,
490
1
A SYSTEM OF MEDICINE.
the tumor may be covered by a carefully adapted concave shield.
The support thus given affords positive relief from pain, and a sense
of security against sudden rupture. In the case of aneurism of the
thoracic aorta, where compression is not available, it has been pro-
posed that coagulation be induced in the sac, when the same may be
reached from the surface, by thrusting into the sac, in different direc-
tions, small wires, or, by means of a fine trocar and canula, several
horsehairs; but as clots thus induced will be loose and irregular, in-
stead of being arranged in compact, concentric layers, as is the case
in spontaneous cures, the method offers no great encouragement.
Galvano-puncture has also been employed successfully in a few cases,
yet as the clot is of the same unsatisfactory character as under the
previous method, the operation does not offer great encouragement.
When employed, each pole is armed with fine steel needles, and both
carried deeply into the sac, yet separated by an inch or more. After
the current from a ten or twelve cell battery has passed through for
an hour, or more, the formation of a coagulum may be hoped for, and
the needles carefully removed.
Palliative Treatment.-All methods of treatment of aneurism
of the aorta may ultimately fail, and the patient be destined to endure
much suffering, and ultimately death will suddenly overtake him.
In such cases it becomes the duty of the physician to do everything
in his power to relieve suffering. Stimulants under all circumstances.
must be carefully avoided. Cold, in the shape of ice-bags, may give
much relief; but at times it becomes absolutely necessary to resort to
anodynes, chloral, opium, or the bromides. When the suffering is
severe, the hypodermic use of morphine will give prompt relief.
Under the most careful management, however, the patient will be
called upon to endure much suffering before death comes to his relief.
STENOSIS OF THE AORTA.
Stenosis of the aorta is of rare occurrence, yet it may exist as a con-
genital condition, or it may be acquired. Congenital stenosis is usually
found at the junction of the ductus arteriosus with the aorta. The
arch above that point is usually more or less dilated, as are the large
vessels springing from it. Below the stricture, the artery is likely to
be more or less contracted, though in some cases it has been found
dilated. The stricture has been found of all degrees, from a slight
narrowing to complete closing. In the latter cases a collateral circu-
lation is kept up through the superior inter-aortic, internal mammary,
and other large branches of the arch, anastomosing with the epigastric,
intercostal, and other branches of the descending aorta. The constric-
tion usually involves about a half inch of the vessel only. It may be
irregular, somewhat resembling a ring, or a regular constriction, as if
tied with a broad string. This condition of the aorta is usually asso-
DISEASES OF THE ORGANS OF CIRCULATION.
491
ciated with some impairment of the valves of the heart, or with hyper-
trophy of the left ventricle.
The causes for this constriction of the aorta have been sought for in
some unusual condition of the ductus arteriosus. If not present at
birth, it is believed to develop within a few days after. Males are
much more liable to this trouble than females. While it is not neces-
sarily attended with any marked symptoms, the subject is always
liable to sudden death.
The diagnosis is rarely made out during life, and were it easily
made, no treatment can be of avail, further than to caution or protect
the patient against violent physical exercise and mental excitement.
EMBOLISM OF THE AORTA.
Embolism of the aorta is of rare occurrence. Clots may, under cer-
tain circumstances, form in the left ventricle, vegetations may become
detached from the valves, fragments from the coagulated contents of
an aneurism, or threads of tissue from atheromatous patches, may be
washed away and carried along the current of blood, but they will
scarcely be large enough to lodge in the aorta. They will rather be
carried on, to be finally arrested in some one of the arteries of the
brain or extremities, producing paralysis or gangrene, as the case
may be.
DISEASES OF THE PULMONARY ARTERY.
The main trunk of the pulmonary artery is subject to much the
same diseases as the aorta, but with great rarity. Atheroma most cer-
tainly may develop in this vessel, and both fatty and calcareous de-
generations are occasionally met with. The condition can scarcely be
detected by any attending symptoms. The weakened condition of the
walls of the vessel will, however, favor a development of an extreme
dilatation of the whole vessel, or of an aneurism with very unusual
pressure in the pulmonary circulation. This condition we have in
many cases of mitral stenosis, in hypertrophy of the right ventricles,
or in emphysema of the lungs. The few cases of aneurism of the
main trunk of the pulmonary artery on record have been associated
with one or the other, or each, of these troubles.
The symptoms of aneurism of the pulmonary artery can with diffi-
culty be distinguished from those of aneurism of the arch of the aorta,
especially so in the earlier stages. The pain and general sufferings
of the patient are much of the same character. From the greater dis-
turbance of the pulmonary circulation, however, the dyspnoea is likely
to be more marked, while cyanosis will often be present, with cough,
high-colored urine, and perhaps anasarca.
The physical signs are not characteristic. The prognosis is neces-
sarily grave. Treatment, except as directed towards palliation, is of
492
A SYSTEM OF MEDICINE.
little avail. Death will be sudden, and probably result from rupture
into the pericardium.
Those smaller branches of the pulmonary artery which ramify
through the substance of the lung are vastly more liable to atheroma
and aneurism than the main trunk of the vessel. Liable to loss of
support from destructive changes in the substance of the lung around,
these same changes probably interfering with the nutrition of the
vessels and rendering them more susceptible to degeneration and
atheromatous processes, we thus find given all the conditions for the
development of aneurism. These must be small in size, but a rupture
of the sac may be followed by alarming hæmorrhage from the lungs,
which need not, however, be necessarily fatal. The violent hæmor-
rhages of phthisis are frequently from this source. During the forma-
tion of vomicæ in the lungs the blood vessels of the heart are exposed.
to the inflammatory and ulcerative processes, yet are so enabled to
resist these that the destruction of a large vessel at least by ulceration
is unusual. Weakened, however, by atheromatous changes, we can.
readily understand how they may dilate into irregular aneurismal
sacs, liable to rupture on any unusual increase of pressure.
The only symptoms of aneurism of the intrapulmonic branches of
the pulmonary artery will be the occurrence of repeated hæmorrhages
in cases in which cavities are known to exist. The violence of the
hæmorrhage will be in proportion to the size of the vessel involved.
Frequently the first hæmorrhage will prove fatal.
The diagnosis will rest mainly on the character of the haemorrhage,
as above stated. Hæmorrhage occurring before cavities have formed
will rarely be from rupture of aneurismal dilatations of the arteries.
The treatment is considered in the chapter on Diseases of the Lungs.
Stenosis. The pulmonary artery, like the aorta, is liable to ex-
treme narrowing, generally of the first part of its course. It is usually
associated with some malformation of the heart; or it may be a result
of an endocarditis, occurring in fœtal life, this being most certain to
produce contraction of the commencement of the vessel. Dyspnœa
and cyanosis, and general venous congestion, usually are the most
marked symptoms of this condition. The most prominent physical
signs will be systolic murmurs at the base of the heart, which may be
traced to the left, but which fail to be heard along the aorta or great
branches of the arch.
There is no treatment for stenosis of the pulmonary artery. Death
is more likely to be from gradual exhaustion than to occur suddenly
and unexpectedly.
Thrombosis and Embolism.-These conditions of the pulmon-
ary artery are by no means uncommon. Thrombi forming in dif-
ferent portions of the venous system may be easily swept along by
the current of blood from smaller to larger branches, until they finally
DISEASES OF THE ORGANS OF CIRCULATION.
493
enter the heart, when, driven into the pulmonary artery, and finally
lodging in some of the larger or smaller branches, embolism is the
result. These emboli may come from various sources. Clots of blood
may form in the systemic veins from various causes, or within the left
ventricle itself; fragments of cancerous, or other, growths may enter
the vessels, all finally being swept into the pulmonary artery.
The symptoms in embolism of the pulmonary artery will vary
according to the size of the vessel occluded. If it be a large branch,
sudden and alarming dyspnoea may set in, with pain in the chest,
pallor, faintness, palpitation, weak pulse, cold sweat, and perhaps.
sudden death. When a small vessel is involved, the symptoms may
be slight or quite overlooked. As the embolus increases in size, as it
is likely to do, the symptoms increase in severity. A slight hæmor-
rhage may set in. Cough, oppression, and evidences of disturbed cir-
culation through the lungs appear. All these symptoms may abate,
and perhaps return again with increased force.
The diagnosis of embolism of the pulmonary artery is difficult and
uncertain. The symptoms appearing suddenly in parturient or ex-
tremely anæmic women, or in patients known to be suffering from
some morbid growth undergoing changes, would go far in establish-
ing the diagnosis of embolism.
The treatment includes little more than an observance of complete
quiet and the free use of stimulants. Indications may be present for
a variety of remedies, but with what confidence of relief can they be
prescribed when the cause of the trouble is mechanical and when the
only hope lies in the direction of preventing further extension of the
clot and of securing its final dissipation-ends only secured through
the force of the circulation!
DISEASES OF THE CORONARY ARTERIES.
The coronary arteries, which supply the walls of the heart with blood,
are subject to the same diseases as the aorta or the arteries of the body.
They may suffer from atheroma, fatty or calcareous degenerations, di-
latation, obstruction or aneurism. In addition to these general causes,
tending to induce changes in the arterial walls, the peculiarity of the
circulation through these vessels may exert an important influence on
their nutrition, and thus upon the pathological changes to which they
are liable. Arising, as these arteries do, from the sinuses of Valsalva,
immediately behind the semilunar valves, the flow of blood through
the aortic orifices upon the systole of the heart, these valves are pressed
against the orifices of the vessels, preventing the blood from entering
these vessels.
As the recoil of the arterial walls takes place, the valves closing, the
blood is driven into these vessels by this force only; consequently, any
494
A SYSTEM OF MEDICINE.
impediment to the ready entrance of the blood into these arteries, as
imperfect semilunars with aortic regurgitation, aneurism of the ascend-
ing arch, atheroma with impaired elasticity of the aorta, would neces-
sarily tend to disturb the circulation through the entire heart-walls,
disturbing the vitality and functional power of the whole organ, ast
well as of the coronary arteries. Thus, fatty degeneration of the heart,
with functional disturbances, angina, and so forth, may fairly be at-
tributed to disturbed nutrition resulting from disease of these arteries.
In atheroma of these arteries, they will be found dilated and soft,
with the usual patchy appearance on the inner surface. Where calci-
fication has taken place, the vessel frequently may be distinctly traced
along the groove between the auricle and ventricle, as a hard cylindrical
table grating under the knife.
There are no reliable symptoms by which these diseases may be
detected during life; for while angina and other disturbances are fre-
quently associated with these conditions, they may exist independent
of them.
Thrombosis or Embolism of the coronary arteries may exist, the clots
forming within the vessels, or, possibly, having been driven into the
same from the aorta. Great pain and functional disturbances have
attended these cases during life.
Aneurism of the coronary arteries has been seen in a few instances,
death having resulted from rupture. Dilatation and rupture may also
occur without the formation of an aneurism. In the case of the late
Dr. Moore, who died suddenly while at the bedside of a patient, at the
post-mortem examination the pericardium was found filled with blood.
After carefully sponging this out, the surface of the heart, more particu-
larly at the base and along the line of the coronary arteries, presented
an ecchymosed appearance, there being plainly blood diffused beneath
the serous covering. An extended careful examination revealed athe-
roma of the coronary arteries, with rupture of the right vessel, extrava-
sation of blood within the muscular substance and beneath the serous
membrane, rupture of the latter between the pulmonary artery and
aorta, thus filling the cavity of the pericardium. The heart-walls
were pale, soft and flabby, showing fatty degenerations.
DISEASES OF THE GREAT VEINS.
The great venous trunks are subject to many of the diseases of the
venous system generally, including inflammation, degeneration, hy-
pertrophy, thrombosis, etc. Varicosity, a condition common in the
smaller veins of certain parts, is unusual, if ever present, in the great
veins.
PHLEBITIS.
Inflammation of the veins is an occurrence of much greater frequency,
at least in the acute form, than acute inflammation of the arteries. The
DISEASES OF THE ORGANS OF CIRCULATION.
495
vena cava and larger veins, however, are not subject to this condition
to the same degree as the smaller veins, not being exposed to the same
exciting causes.
Etiology. The causes of phlebitis are extremely various. One
of the most frequent is the formation of clots within the vessel; this
will be considered under the head of thrombosis. Phlebitis is fre-
quently the result of the extension of an inflammation from the sub-
stance of the organ to which the veins belong, in which case their
outer coats only will show changes, the inner remaining normal in
appearance. Poisoned wounds, or other injuries, may also result in
phlebitis. In these cases there will be generally a tendency for the
inflammation to extend along the vessel for some distance. Thicken-
ing, softening, or destruction by suppuration may follow, or clots may
form, as in phlebitis from other causes. These may soften and become
absorbed, or degenerate into a suppurative mass. Erysipelas, car-
buncle, inflammation and suppuration of bones, or simple diffuse
cellular inflammation may each give rise to inflammation of veins,
with, perhaps, accompanying thrombosis. It springs up not infre-
quently in the uterine veins of puerperal women, and plays an im-
portant part in cases of phlegmasia alba dolens. In some cases of
phthisis pulmonalis also, for some not easily explained reason, phle-
bitis of the iliac, and some other large veins, has occasionally been
found.
Symptoms. The symptoms of phlebitis vary according to the
size, number and extent of veins involved; pain and tenderness along
the course of the vessel will always be present. If a superficial vein.
is involved, a hardness of the vessel may be detected, and generally a
red line of discoloration may be traced along its course. If the deep
veins are involved, the hardness and redness may be absent. In the
latter case the superficial veins may appear enlarged, and even dis-
tended, without being painful. Edema of the limb will be more or
less marked, the swelling being usually colorless and hard.
The constitutional symptoms may be very slight in simple limited
phlebitis, but if pus forms, or embolism or thrombosis occurs, high
fever of a typhoid character may appear, and even death supervene
with every indication of pyæmia. When the outer coat or sheath of
the vessel is primarily involved, the inflammation may follow the vein
for some distance, finally, at some favorable point, an abscess rapidly
forming, with pain and throbbing and marked constitutional symptoms.
This form rarely occurs except from injury in persons of broken health
and with bad hygienic surroundings.
Inflammation of the vena cava or innominate vein, the largest in
the body, rarely occurs, and is not recognized by any characteristic
symptoms. Such is not the case, however, with the portal vein. This
vessel appears specially prone to inflammation and its results, and the
496
A SYSTEM OF MEDICINE.
diseased processes are accompanied by more or less characteristic
symptoms. Purulent inflammation of the portal vein, or pylephlebitis, is
not an uncommon occurrence. It may be traumatic in its origin.
This, however, is very rare.
A few cases have been reported where pins, needles and other foreign
bodies, swallowed by insane and other persons, have penetrated the
walls of the stomach, and so injured some of the gastric or other veins,
as to induce an inflammation which, by direct extension, or by pro-
moting the formation of an embolus which has been swept into some
branch of the portal vein, has thus induced a suppurative inflamma-
tion of that vessel.*
A more frequent starting-point of this disease, however, will be found
in an inflammatory and, perhaps, suppurative process involving some
of the organs returning their venous blood to the portal vessels. Thus
the cæcum in typhlitis or perityphlitis, disease of the vermiform pro-
cess, ulcerative processes of the stomach, gall-bladder and hepatic
ducts, have each given rise to a suppurative inflammation of the portal
vein.
Morbid Anatomy.-The morbid changes in the walls of veins
resulting from inflammation will vary according as the process com-
mences in the inner or outer coats. When commencing in the inner
coat, it will usually be the result of the pressure of a clot plugging the
vessel. The lining membrane is then found thickened, opaque, rough,
and adherent to the clot. When the inflammation commences from
without, the sheath as well as the outer coat will have become much
thickened. When suppuration takes place, the pus will infiltrate the
loose tissues of the sheath, forming an abscess even without involving
the coats of the vein. The pathological changes in pylephlebitis are
strongly marked. The walls of the vessel are much thickened, appear-
ing in some cases as hard cords. The capsule of Glisson is thickened,
red, or infiltrated with pus. The lining membrane is opaque, gray in
color, and much softened. From its thickened condition the vessel
remains open when divided, failing to collapse, as do veins when in a
normal condition. The diseased portion will usually be found filled
with thin pus. Separating the diseased from the healthy portion of
the vein, there will usually be found a firm clot closely adhering to
the vessel walls. The destructive process may, in some places, com-
pletely destroy the outer walls of the vessel, and form small cavities
filled with pus. In such cases the hepatic tissue may become involved
in the suppurative process, resulting in abscesses of various sizes.
Symptoms. The symptoms of pylephlebitis are often directly
associated with those of the inducing cause, as perityphlitis, ulceration
of vermiform process, gallstones, chronic peritonitis, etc. The com-
* Ziemssen's Cyclopædia, vol. ix., pp. 807, 808.
DISEASES OF THE ORGANS OF CIRCULATION.
497
mencement of the attack is usually attended by a chill, sometimes
severe, with pain in some portion of the abdomen, usually referred to
the starting-point of the disease. The abdomen soon becomes dis-
tended, hard and sensitive. Nausea and vomiting set in early, and
continue through the course of the disease. The introductory chill is
followed by hot fever and sweat, the fever, however, not disappearing
as in an intermittent; the chill may be repeated daily, varying in in-
tensity according to the gravity of the case. Great prostration and
rapid exhaustion show themselves, the eyes become sunken, the skin
jaundiced, the pulse small and rapid, the breathing hurried and short,
the tongue dry and coated; both liver and spleen appear swollen and
tender; the urine becomes scanty, and, as the disease progresses, it
nearly ceases. Diarrhoea is usually present, and rapid emaciation ac-
companies the great prostration. Increased jaundice, clammy sweat,
stupor or delirium, usually precede the fatal termination. The disease
may run its course within ten days or two weeks, or it may last for
several weeks; the more marked the pyæmic symptoms, the earlier
death is likely to occur. Recovery is a rare exception.
Diagnosis. The diagnosis of inflammation of superficial veins is
easily made, having to be distinguished only from inflammation of
the lymphatics and, perhaps, erysipelas. In the former case the lines
of redness are finer, more numerous, and have a distribution corre-
sponding to the course of the lymphatics rather than to that of the
veins. In erysipelas the redness is evenly diffused over the surface,
with well-defined margins. Both these conditions, however, may be
associated with phlebitis, and the combination tends particularly to-
wards pyæmia.
Diagnosis of inflammation of the largest veins, with the exception,
perhaps, of the portal, is not so easily made. The deep position of
the largest veins, and the fact that disease of these vessels is usually
associated with disease of the adjoining tissues or organs, render the
diagnosis difficult to be made. With the large trunks of the extremi-
ties, including the iliacs and subclavians, the difficulty is less. The
tenderness, swelling and hardness along the course of the vessel will
be the principal diagnostic signs.
In suppurative phlebitis of the portal vein, the disease may be taken
for intermittent fever from the repeated chills followed by fever and
sweat. They have, however, nothing else in common. The pain and
tenderness of the abdomen, with the incomplete apyrexia, should lead
to a correct diagnosis. Obstructions of the gall-ducts, either from gall-
stones or catarrhal inflammation, may be mistaken for pylephlebitis.
Here the absence of chill, and the great prostration and emaciation,
with the accompanying jaundice, should protect from error in diagno-
sis. Abscess of the liver of an idiopathic origin might also be mistaken
for this disease. The chill and fever, with enlargement and tenderness
VOL. I.-32
498
A SYSTEM OF MEDICINE.
of the organ, will be similar; they differ, however, in origin; and in
simple abscess there will not be the prostration, diarrhoea, or emacia-
tion which mark the pyæmic condition of suppurative phlebitis of the
portal vein.
Treatment. The great and all-important consideration in the
treatment of inflammation of the veins of the extremities is rest and
external support. The patient must be kept perfectly quiet in bed,
and the limb elevated and carefully bandaged. Hot fomentations
will not only be grateful and comfortable to the patient, but will aid
materially in subduing the inflammation. Should abscesses form,
they should be opened early, and poulticed both before and after
opening. Any continued œdema will be best overcome by the use of
an elastic bandage, which should be worn after getting on the feet
until all tendency to swelling has disappeared. Inflammation of the
vena cava, whenever present, will be so associated with some other
disease, as abscesses, tumors, etc., within the chest or abdomen, that a
diagnosis is nearly or quite impossible, and treatment can only be
given to the primary disease.
In suppurative inflammation of the portal vein, Von Schueppel says,
"We are entirely impotent as we can obtain no influence over the dis-
eased process, nor can we prevent septic infection of the entire organ-
ism." We may hope, however, before the pyæmic condition has arisen,
by the employment of a well-selected remedy, to subdue the inflam-
mation, and thus arrest the progress of the disease.
Among those more likely to be indicated may be mentioned the fol-
lowing:
Aconite.—In the early stage, or later when there is much fever and restlessness.
Arnica.-When the trouble has been of a traumatic origin.
Arsenicum.-Edema of parts, tendency to renal dropsy or to gangrene, great
prostration, symptoms of blood-poisoning. (Apis, China, Secale.)
Baptisia.-Typhoid symptoms, with dark, offensive stools, dry, sore tongue,
dark and scanty urine. (Lach., Rhus, Bry.)
Hamamelis.-Veins enlarged and varicosed, both externally and internally.
(Puls., Merc.)
Hepar.—Tendency to formation of abscesses.
Symptoms may also call for Lyc., Nux. v., Sulph., Calc. carb., Phos.
DEGENERATION.
Atheroma.-A degenerative process, occurring frequently in arte-
ries, probably never occurs in veins. Calcareous deposits are, however,
not infrequently found in the walls of veins, more especially of those
involved in varicose enlargement. The deposits occur in plates be-
neath the lining membrane, thinner than those found in arteries, but
of the same composition. Dr. James Kitchen* reports a remarkable
* Am. Journal of Hom. Mat. Med.
DISEASES OF THE ORGANS OF CIRCULATION.
499
case of calcification of the veins of the omentum, where the process was
so complete that the whole omentum was stiff and rigid. The great
venous trunks are peculiarly exempt from this change..
PHLEBOLITES.
Remarkable concretions are sometimes found within veins, about
the neck of the bladder, or in other veins with varicose enlargements,
as well as occasionally in the veins of the lungs and spleen. These
bodies are whitish in color, rounded in form, chalky in composition,
and composed of concentric layers similar to urinary calculi. The
origin of these bodies is not well understood. It is generally consid-
ered, however, that they originate from a small blood-clot, which,
shrinking into a firm mass, forms a nucleus around which calcareous
matter becomes deposited. They may vary in size from a pea, and
smaller, to a large bean. They seldom give serious trouble.
VARICOSIS.
One of the most common pathological conditions of veins, is that
known as varicosis, consisting in an increase of diameter, length, and
thickness of the walls, and more frequently involving the superficial
vessels of the lower extremities, giving them, from the irregularity of
the dilatation, a knotted appearance. It is more particularly the por-
tion of the walls above the valves that becomes dilated and generally
much thinned, although their outer coat may be much thickened.
As already intimated, varicose veins are more common in the lower
extremities; they not infrequently appear in the spermatic cord, in-
ducing varicocele, or in the veins of the rectum, giving rise to hæmor-
rhoids. They have also been found in the veins of the neck and upper
extremities, and even in those of the oesophagus and stomach. The
veins at the base of the bladder are, at times, involved, as may be those
of the vulva of the female in pregnancy.
Causes. The causes of varicose veins may be found:
1st. In some impediment to the ready flow of the blood through the
heart or lungs, retarding the return of the blood from the veins, and
thus increasing pressure upon their walls.
2d. From pressure upon large trunks of the veins themselves, as
from a truss at the groin, a tight garter around the leg, a gravid uterus,
pressure of a tumor, an over-distended rectum, or employment requir-
ing prolonged standing. All these conditions, tending to increase the
blood-pressure within the veins, are calculated to promote the forma-
tion of varicose veins.
The morbid changes taking place in varicose veins are gradual and
progressive. At first, a simple dilatation and thinning of the walls.
Soon, however, the walls, and particularly the middle coat, will be-
come thickened as well as the connective tissues around the vessel;
500
A SYSTEM OF MEDICINE.
the veins thus become larger, harder, and more tortuous than normal.
The valves become thickened, and the veins more dilated immediately
above, thus acquiring a knotted appearance. After long continuance,
the vessel may become more superficial by absorption of covering
tissues; the vitality of the skin becomes impaired, and an ulcer ap-
pears, or, perhaps, rupture of the vein takes place, followed by serious,
or even fatal, hæmorrhage. Clots may form as a result of the sluggish
flow of blood, these being either swept on to the heart, and then to the
lungs, or, remaining permanently at the point of formation, induce in-
flammation of the lining of the vessel, or shrink into a firm semi-
organized mass, or, perhaps, form the nucleus of a phlebolite.
Treatment.-The treatment of varicosis includes:
1st. The removal of the cause, when that is possible.
2d. The maintenance of a horizontal position.
3d. External support by bandage or elastic stocking, when the veins
of the legs are involved, and a suspensory bandage in varicocele.
4th. Obliteration of the vessel by surgical operation. The several
methods for accomplishing this end include the application of caustics
over the vessel, galvanic puncture, injection of perchloride of iron,
subcutaneous division, and acupressure. All of these operations, how-
ever, are attended with more or less danger of being followed by phle-
bitis, and perhaps thrombosis, while none of them are certain of being
followed by a radical cure.
5th. Medical treatment. The remedies which have been found most
useful in varicosis are as follows:
Hamamelis.-Dr. Hughes says "In the various forms of varicosis this is the
prince of remedies." It seldom fails to benefit, even if a cure is not effected. While
the remedy is used internally, the tincture, diluted with water, may be applied exter-
nally. The special symptoms calling for its use are: veins dilated, sore, and with a
distended forcing feeling in the varices.
Arsenicum.-Where the veins are of a livid red color, and attended with se-
vere burning pain.
Belladonna.-Erysipelatous inflammation along the course of the veins.
(Rhus tox., Puls.)
Arnica.-When the patient has to be much on his feet, or when the trouble is of
a traumatic origin.
The following remedies may be found useful in some cases: Aconite,
Esculus hip., Ambra, Calcarea carb., China, Graphites, Hepar, Krea-
sotum, Lachesis, Nux vom., Sepia, Sulphur, Zincum.
THROMBOSIS AND EMBOLISM.
An important pathological condition, associated with both arteries
and veins, is that of thrombosis and embolism. By the former term is
understood the formation of a clot in some portion of the vascular
system, while embolism signifies the transference of this clot, or some
portion of it, by the current of blood to some smaller vessel, blocking
DISEASES OF THE ORGANS OF CIRCULATION.
501
up the same. Thrombosis, or the formation of clots, may take place
in the heart, arteries, veins, or capillaries. Embolism, or the lodgment.
of a clot swept from its point of formation, may occur in any portion
of the arterial system, more frequently in the arteries of the brain or
extremities. While in the venous system, emboli are more liable to
lodge in some of the branches of the portal vein, or of the pulmonary
artery into which, in the latter case, they have been carried from the right
or venous side of the heart.
Thrombosis of the heart will be found fully considered in the chapter
on diseases of that organ. Capillary thrombosis plays an important
part in the pathology of the lungs, kidneys, liver, and other organs,
and usually tends towards the formation of hæmorrhagic infarctions,
or of small abscesses.
Causes of Thrombosis.-The most potent causes of thrombosis
are undoubtedly found, 1st, in disturbance in the circulation of the
blood itself; and 2d, in altered conditions of the lining membrane of
the vessels.
Any cause tending to retard the circulation in either the arteries or
veins is favorable to the formation of a thrombus. Venous circula-
tion being always more sluggish than arterial, the tendency is greater
for their formations in veins than in arteries. The impeded circulation
in varicose veins often induces thrombosis. Wounds of veins, arterial
pressure, general feebleness of circulation, and syncope, may all tend
to promote the formation of a thrombus. Inflammation or degenera-
tion, particularly the calcareous form, either in arteries or veins, by
producing a roughened condition of the lining membrane, favors throm-
bosis. Again, an embolus carried to and lodged in a vessel, may be-
come a starting-point for the formation of a new and large thrombus.
Inflammation of veins is sometimes, no doubt, a cause of throm-
bosis, yet more frequently thrombosis will bear the relation of cause
rather than that of effect to phlebitis, inflammation resulting from
pressure and irritation of the clot.
Thrombi are found more frequently in the veins of the legs and
pelvis, where the venous circulation is opposed by the force of gravity,
and where varicosis or dilated veins add to the impeded circulation.
The portal vein is another frequent seat of thrombosis, the peculiarity
of the circulation through the liver, with the numerous diseases of or-
gans from which the portal veins spring, favoring this condition.
Emboli in the arterial system will be found to have arisen from the
left side of the heart in the vast majority of cases. Endocardial in-
flammation inducing lymph deposits upon the ventricular walls, these
may become detached and swept into the aorta with the current of
blood, ultimately lodging in some of its branches, frequently reaching
the brain, or perhaps some of the more distant organs or part of the
body. Not only fibrinous clots may thus form an embolus, but small
502
A SYSTEM OF MEDICINE.
fragments of calcareous matter may become detached from the surface
of degenerated arteries, or fragments of broken-down tissue from a
sloughing wound or abscess may enter the general circulation, and
thus form the substance of an embolus.
Symptoms and Results.-The symptoms of embolism or throm-
bosis are very similar, if not identical. In both cases the symptoms
result from obstructed circulation. When the obstruction is in an artery,
function and nutrition will be suddenly impaired, and even death of
the part from gangrene may supervene. Embolism or thrombosis of
veins, when in the limbs, will be accompanied with oedema and ten-
dency to the formation of abscesses. Pain at the seat of the obstruc-
tion is usually present in all cases accompanied by tenderness upon
pressure. Obstruction of arteries is usually more sudden in its ap-
than in veins, and the symptoms are more severe. In most
pearance
cases, when an obstruction has been diagnosticated, it is difficult to de-
termine whether the obstruction is an embolus or a thrombus. If an
embolus, there should be detected in some other organ or point evi-
dence of a thrombus or diseased vessel from which the obstruction
might have been carried.
Embolism or thrombosis of the vessels of different organs will induce
very different symptoms and results. Mention should therefore be
made of the results of obstruction of different vessels.
OBSTRUCTION OF VESSELS OF THE BRAIN.
The arteries of the brain are more liable to become obstructed than
the veins, and the obstructing plug will, in the majority of cases, be
an embolus swept from the heart. Thus, both acute and chronic val-
vular or endocardial disease are liable to induce embolism of the brain.
A vegetation from a valve, a mass of fibrin or lymph, a scale of calca-
reous matter, may at any time become detached and carried into the
aorta, and thus through the carotids into the brain. Thrombosis of
any artery of the brain may occasionally occur, yet the middle cere-
bral, from its more direct line with the internal carotid, will more fre-
quently be the vessel involved.
The symptoms of obstruction of the vessels of the brain are sud-
den and alarming in their character. They may simulate apoplexy,
epilepsy, or syncope. The symptoms may be slight or severe, accord-
ing to the size of the vessel obstructed. Immediate death is not so
liable to occur as in apoplexy. A degree of paralysis may follow the
seizure, and congestion of some portions of the brain, anæmia of others,
followed by softening, are liable to supervene.
OBSTRUCTION OF THE PULMONARY ARTERIES.
The symptoms of obstruction of these vessels will be a "sudden em-
barrassment of respiration, great dyspnoea with coldness, pallor and
DISEASES OF THE ORGANS OF CIRCULATION.
503
clamminess of the skin, pallor and lividity of face; feebleness, rapid-
ity and irregularity of the pulse, followed by death, sometimes after
an interval of several days, sometimes quite suddenly."*
These obstructions are usually embolic in their origin, and may
have arisen from almost any point of the venous system, or from the
right ventricle itself. From necessity, clots forming in any of the sys-
temic veins must find their way finally to the heart, and from there
into the pulmonary arteries. If death do not immediately result, pul-
monary apoplexy may follow, or inflammation of a considerable por-
tion of the lung supervene.
OBSTRUCTION OF VESSELS OF THE EXTREMITIES.
When in the arteries, these obstructions are nearly always embolic,
the clot having arisen at the heart or at some other point. Occasionally
they may arise from a disease of the artery at the point of the obstruc-
tion. Sudden acute pain at the point of obstruction, loss of pulsation
below, with falling of temperature and pallor of the surface of the limb,
will immediately follow the blocking up of the vessel, while later,
numbness, loss of vitality, and even gangrene, may follow.
Embolism of the veins of the leg occurs less frequently than of the
arteries. Clots may form, and they may occasionally become lodged
at another point, but the venous blood flowing from smaller to larger
branches, any floating masses are more liable to be carried to the heart
and from there to the lungs, producing embolism of the pulmonary
artery.
The results of embolism of the veins or arteries will vary according
to the nature or source of the embolus. Arterial emboli will usually
have arisen from the heart, and be composed of firm fibrinous matter
slowly undergoing change. Venous emboli, on the other hand, are
more frequently from some suppurating surface, and serve to convey
septic matter to the organ in which they become lodged, giving rise to
abscesses in the same, and to general pyæmic symptoms. The liver
and lungs are notably exposed to the danger of abscesses from this
source.
Treatment. The treatment of thrombosis or embolism will vary
according to the seat of the trouble and severity of the symptoms.
No specific rules or remedies can be given for all cases. When of the
brain, the treatment will be much the same as in apoplexy. Quiet,
freedom from all excitement, noise and from stimulation will be of
great importance. When in the liver or lungs, and accompanied with
pyæmic symptoms, alcoholic stimulation may be of great importance.
When in the extremities, elevation of the limb and the application of
artificial heat will tend to promote the collateral circulation and pre-
* John Syer Bristowe, M.D., Reynolds's System of Medicine, vol. ii., page 896.
504
A SYSTEM OF MEDICINE.
serve the vitality of the part. Where gangrene supervenes, amputa-
tion may become a necessity. Gangrenous surfaces should be dressed
with antiseptic poultices of charcoal, or flaxseed meal mixed with a
solution of carbolic acid or "Platt's chlorides." When abscesses form,
they should be opened. Abscesses forming in the liver, and clearly
recognized, may be advantageously aspirated.
The system should be sustained by milk, animal broths, beef-tea,
and, in some cases, by brandy.
The symptoms, both subjective and objective, may call for a large
number of remedies. At the commencement of an attack, indications
will be likely to be found for: Aconite, Arnica, Arsenicum, Belladonna,
Bryonia, Camphor, Gelsemium, or Veratrum viride.
Later in the course of the disease, we may consult: Arsenicum
iodat., Apis, Carbo veg., Digitalis, Hepar, Lachesis, Mercurius, Nux
vom., Rhus tox., Phosphorus, Secale, Sepia, Sulphur.
For obstruction of vessels of the brain: Aconite, Arnica, Belladonna,
Hyoscyamus, Lachesis, Opium, Pulsatilla, Stramonium.
For obstruction in the portal vein: Aconite, Arsenicum, Belladonna,
Digitalis, Hepar, Mercurius, Nux vomica, Phosphorus.
For obstruction of vessels of the lungs : Aconite, Arsenicum, Cal-
carea carb., Belladonna, Bryonia, Digitalis, Hepar, Lachesis, Lauroce-
rasus, Phosphorus, Rhus tox., Spigelia, Veratrum alb.
For vessels of extremities: Aconite, Arnica, Apis, Belladonna, Carbo
veg., Hamamelis, Hepar, Lachesis, Mercurius, Rhus tox., Secale.
Indications for many other remedies may be found in diseases of
the veins, embolism, and thrombosis. In all cases careful study of
symptoms and comparison of remedies should be made, while the
hygienic, mechanical, and surgical treatment should each receive due
attention.
DISEASES OF THE ORGANS OF DIGESTION.
A. DISEASES OF THE MOUTH.
DISEASES OF THE GUMS.
BY CLARENCE M. CONANT, M.D.
GUM-BOILS.
Synonyms. Parulis, Alveolar abscess.
Definition. A circumscribed phlegmonous inflammation of the
external side of the fibrous gum-tissue, and also of the dental and
alveolar periosteum.
Etiology. The gum-boil arises in almost every case from a de-
cayed tooth, and is really a sequel of dental caries. It may also be
seen on a large scale as a secondary affection of scurvy, and not unfre-
quently follows the abuse of certain drugs, as mercury, phosphorus, etc.
Pathology. When a tooth becomes carious, the dental pulp usu-
ally becomes inflamed, and always so when the cavity in the tooth
extends into, and communicates with, the pulp. This inflammation
is sometimes averted by a formation of secondary dentine within the
pulp-cavity opposite the external caries, so that when the destructive
process reaches the pulp-cavity, it is yet shut off from that sensitive.
substance by the adventitious formation of dentine. The pulp once
inflamed, the trouble rapidly extends to the periosteum covering the
root of the tooth, and to the alveolar process of the jaw. In rare cases
the periosteal lining of the body of the jaw is attacked, producing a
chronic periostitis. The fibrous and mucous tissues of the jaw form
a circumscribed swelling, which suppurates, bursts, and discharges
through an opening in its mucous covering, or rarely through an
orifice in the adjacent integument, forming a fistula dentalis.
Symptomatology. The symptoms of a gum-boil are heat, red-
ness, swelling, and a throbbing-drawing pain felt in any other abscess.
The inflammation develops suppuration in a few days, and after dis-
charging freely, shrinks up and heals over speedily. Gastric disorders
and constipation not unfrequently, especially in young children, appear
as concomitants.
Diagnosis. Gum-boil might be mistaken for epulis, but its severe
pain, tenderness, and redness serve as distinguishing features. An
incipient wisdom-tooth has been taken for a gum-boil; but the posi-
tion of the swelling serves to differentiate, the tooth pushing through
506
A SYSTEM OF MEDICINE.
the upper surface of the gum, while the boil affects its lateral surface,
and is usually located near its base.
Treatment. Whatever tends to preserve the textural integrity of
the teeth tends to prevent the formation of alveolar abscess. Hence,
the teeth should be kept clean, and the accumulation of tartar removed
from time to time; the correction of an acid stomach by the indicated
remedy is also advisable. When a tooth is carious, it should be either
filled or removed.
The diet should consist of milk, meat-broths (especially beef-tea),
and gruels. Oatmeal gruel, acting as a gentle laxative, and being
nutritious, may be added to the list. The mouth, especially before.
eating, should be thoroughly rinsed with hot water, which may con-
tain a small percentage of Condy's fluid, or a solution of chlorides,
while the abscess is discharging.
Therapeutics.-Mercurius.-Aching and throbbing pain in, and swelling of,
the gum, which is painful to the touch. Fotid odor from the mouth. Salivation.
Constitutional tendency to gum-boils.
Hepar sulph.-Soft swelling of the gum, with great tenderness to touch;
throbbing pain; the swelling softens, but does not open.
Silicea.-Swelling of the alveolar (?) periosteum. Gums very sore and inflamed.
Discharge of offensive matter from openings near the roots of the teeth or from the
gums. The abscess heals slowly.
Compare also: Aconite, Belladonna, Calcarea carb., Hydrastis, Phos-
phorus, Staphisagria, Sulphur.
An old-fashioned fig-poultice, or even a fig roasted, and put on the
swelling as hot as it can be borne, will often relieve the pain and hasten
the issue. Should suppuration delay, it may be hastened by any
poultice prepared, that of linseed-meal being chiefly recommended.
Should the swelling fluctuate and not open, it should be lanced deep.
and low, without delay. Otherwise the pus may burrow, forming
sinuses and fistulous openings in the cheek, or even necrosis of the
jaw.
EPULIS.
Synonyms. French, Épulide; German and Latin, Epulis.
Definition. A smooth, hard, or semi-elastic, rounded or lobulated
tumor, usually painless, arising from the gum. The causes which give
rise to this growth are not known.
Pathology. Many authorities regard epulis as a benign fibroid or
fibro-plastic growth, which rarely becomes malignant. Careful obser-
vation, however, while establishing the harmless nature of this growth
in its early stage, proves also the danger of neglecting it; if allowed
to develop, it may ultimately burst through the covering mucous.
membrane, and exhibit many of the characteristics of a malignant
ulceration.
Round
The histological elements differ widely in different cases.
and spindle cells, and giant cells in great numbers, are found in vary-
DISEASES OF THE ORGANS OF DIGESTION.
507
"
ing specimens. Osseous trabeculæ are also seen extending down into
the subjacent bone, binding the tumor to it.
Symptomatology.-Epulis arises from the alveolar periosteum
of the lower jaw, usually, and appears on the side of the gum or be-
tween two teeth, as a small, hard, painless swelling. It grows slowly
in most cases, and gradually loosens and pushes up and out the adja-
cent teeth, the growth assuming the form of a round or, more often,
lobulated, semi-elastic tumor. This tumor is painless, does not bleed
easily, and, if pedunculated, may be readily raised with the forceps,
and freely inspected. The protuberances now become bared of their
mucous covering, are of a red color, and gradually assume a malig-
nant ulceration, when the term myeloid epulis is applied to the
growth.
Authors mention the following varieties, which, practically, are dif-
ferent stages of one pathological process: (a) the simple fibro-plastic
tumor; (b) round-celled sarcoma; (c) the myeloid tumor.
Diagnosis. An incipient wisdom-tooth might simulate an epulis
but that the hardness and pain stand in reverse order; an epulis is
hardest when painless, and rarely appears on the posterior aspect of
the gum.
Treatment. The treatment is chiefly surgical. The tumor must
be removed, and with it, the bone traversed by the osseous trabeculæ ;
at least, the bone should be thoroughly scraped to avoid prompt recur-
rence of the growth.
The remedies to be consulted are: Natrum muriat., Calcarea carbon.,
Silicea, Thuja.
FUNGOID TUMORS OF THE GUMS.
Fungoid tumors of the gums (encephaloid cancer) are very rare.
They are readily recognized by their characteristic fungoid appearance,
profuse and readily excited bleeding, and rapid growth. As the can-
cerous cachexia is well marked in this form of cancer, the diagnosis
is still more readily made.
For treatment, compare hints given under cancerous affections in other
sections.
SALIVARY FISTULA.
Definition. An abnormal orifice in Steno's duct, leading to a dis-
charge of the secretion of the parotid gland upon the face instead of
into the mouth.
Etiology. A salivary fistula is caused by the division of Steno's
duct during an operation, or by the formation of an abscess in or about
the duct, breaking outwardly.
Symptoms.-An orifice is seen in the cheek from which saliva
runs down over the face.
Treatment. The treatment is purely surgical. Through that part
508
A SYSTEM OF MEDICINE.
of the duct remaining with the gland, a probe, wire, or catgut is passed
into the gland from the mouth. Or, should the duct be merely severed
and the natural orifice not be obliterated, that orifice should be sought
and the probe passed through it so as to unite the two parts of the
duct. The edges of the fistulous opening on the cheek are now fresh-
ened and brought together, and retained in place by sutures until the
healing process is well established. The treatment of salivary fistula
always requires considerable time and patience, and a depressed scar
is left at the seat of the fistula.
DENTAL FIStula.
A tube or pipe leading from the root of a tooth, opening into the
mouth or on the face, discharging through its hard callous edges a
pus-like, ichorous fluid. It results from a gum-boil, and from a dental
and alveolar periostitis and caries. It does not heal spontaneously,
and is differentiated from a salivary fistula by the nature of the dis-
charge proceeding from it, consisting of pus, ichor, or blood, but never
containing saliva. The treatment is largely surgical, but the following
remedies may be exhibited with excellent results.
Causticum.-Tedious suppuration of the gums.
Silicea.-Discharge of offensive matter from openings near the roots of the teeth.
Calcarea carb.-The lower jaw is affected.
Consult: Askalabotes, Ratanhia, Sulphur.
THE MORE COMMON AFFECTIONS OF THE TEETH.
BY CLARENCE M. CONANT, M.D.
ODONTALGIA-TOOTHACHE.
First and chiefly, toothache is a sign of decayed or of decaying
teeth. The pulp and the periosteum covering the roots of the teeth
are liable to become inflamed, giving rise to excruciating toothache.
Dental periostitis is common in syphilitic subjects and in persons who
have taken too much mercury or iodide of potassium. In some in-
stances the formation of secondary dentine, or dental exostoses, takes
place, and occasions severe pain. Some authorities mention a rheu-
matic inflammation of the fibrous gum-tissue as a cause of odontalgia,
but the existence of such an inflammation has never been positively
demonstrated, and is doubted by many.
The pathology of toothache is mostly identical with that of dental
caries, which process is practically a chemical process. Bone caries
is always preceded by inflammation, and the toothache arising from
dental caries is a sign that the destruction of the tooth-substance is
already far advanced. Dental caries is a progressive and gradual dis-
DISEASES OF THE ORGANS OF DIGESTION.
509
integration of the teeth in which the lime salts are first absorbed, the
organic matter soon likewise disappearing. An acid condition of the
stomach, mouth, or system in general, seems to favor this process.
Inflammation of the periosteum often follows caries, and extends to
the pulp of the tooth unless headed off by the formation of secondary
dentine, which in itself may give rise to severe toothache. We now
have redness and painful swelling of the gum, pain in the tooth, and
frequently destruction of the entire tooth.
Two kinds of exostoses are found on and near the teeth: The first,
a true exostosis or osteoma, which is a bony tissue produced by in-
flammatory action, and found in small nodes on the roots of the teeth,
sometimes in such profusion as to give the root the appearance of
general enlargement, causing much pain by pressure upon contiguous
tissues, and offering a very serious obstacle to the extraction of the
tooth. These osteoma are often seen. Not so with a very rare dental
exostosis, called by Virchow the odontoma. These are small tumors
of dentine and enamel, arising from undeveloped teeth left in the
alveoli.
Symptomatology.-Pain in a single tooth, or in a whole row of
teeth, sometimes extending through the jaws into the ears and about
the eyes, and even into the head and neck. The pain is sometimes
continuous, but more often paroxysmal. It is of a dull or hard
aching, or of a sharp, lancinating, darting ("jumping toothache ")
character.
Diagnosis. When pain occurs as located above, and the teeth are
found tender and carious, the diagnosis is certain. But should the
teeth be sound, and the pain periodic and not limited to a well-defined
area, facial neuralgia may be suspected. Pains in the teeth occur not
infrequently with affections of the ear, but the soundness of the teeth
and the symptoms obtained by a careful examination of the ear are
sure to establish the diagnosis.
Treatment. The teeth should be brushed always, after eating, with
cold water and a soft dentrifice, to secure absolute cleanliness; no
tooth-powder should contain charcoal or other hard particles, as these
scratch the enamel and lead to caries. After swallowing acid foods,
drink, or medicine, the mouth should be well rinsed with cold water.
So soon as any caries of the teeth is detected, it should be carefully
cut away, and the cavity filled with gold, or the tooth should be ex-
tracted. To attain this result, persons with presumably sound teeth.
should have them examined three or four times a year by a competent
dentist.
Therapeutics.-Antimonium crudum.-Boring, digging, tearing, jerk-
ing pains in hollow teeth, sometimes penetrating into the head and nose, in the even-
ing, in bed, after eating, and from taking cold water into the mouth; touching the
tooth with the tongue causes pain as if the nerve were torn. Better when walking in
open air
510
A SYSTEM OF MEDICINE.
Ca
Arnica.—Bleeding after the extraction of teeth. Pain and swelling from wear-
ing false teeth, or after filing out, filling, etc. Throbbing toothache.
Arsenicum.-Very debilitating toothache. Jerking, tearing, burning pains,
referred to the gums. Worse when touched, when lying on the painful side, when at
rest, and from cold; better from warm applications, or when exposed to the heat of the
stove, or when sitting up in bed. The teeth feel too long, and are loose.
Belladonna.-Toothache in women and children. Toothache after eating,
not during eating. Right upper teeth ache all night. Pain extends into the ear.
Great restlessness, nervousness, excitability, with running about and crying.
Carbo vegetabilis.-Teeth decay rapidly. Drawing-tearing toothache, worse
when touched by the tongue, and after eating. Molars and incisors are affected. Teeth
loose and ulcerated.
Chamomilla.-Stitching, digging, gnawing toothache in children and in
women before menstruation, as if from taking cold. Pain worse during and after
eating warm food, especially from drinking coffee; worse at night. Left-sided and in
the lower jaw; but often no particular tooth can be pointed out as aching.
Cinchona.-Toothache in nursing women while the infant is at the breast.
Throbbing, tearing, jerking, or drawing toothache, with great pressure. Periodical
toothache, during the sweat.
Coffea.—Most severe and agonizing stinging, jerking, intermittent toothache,
worse while chewing, from warm drink, and at night. Relieved for a time by ice or
ice-cold water held in the mouth.
Glonoine. After taking cold from overheating; pulsating throbbing pains like
a pulse in the teeth, or a drawing pain. Sudden waves of spontaneous aggravation
in the right, and then left, side of the whole head, jaw, and ear.
Hamamelis.-Passive, dark fluid hæmorrhage from the gums after the extrac-
tion of teeth. Toothache in sound (?) teeth, worse in a warm room.
Kreasotum.-Bad odor from, and much drawing aching pain in, carious teeth,
extending to face, temples, and ears. Milk-teeth decay and ache so soon as they
appear. (Staph.)
Magnesia carb.-Ailments from cutting, and slow eruption of (all teeth),
wisdom teeth especially. Toothache worse at night; it drives one out of bed (also
Magn. phos.). Toothache of pregnant women.
Mercurius.—Pulsating toothache at night, in the evening in damp weather, in
children; from caries, or when the dentine is inflamed. Tearing, lacerating, draw-
ing, stinging pains, which affect the whole jaw and side of the face, and extend into
the ears.
Worse from the heat of the bed, and from both warm and cold things, but
better from rubbing the cheek. Teeth loose, gums swollen, ulcerated, and retracted
from the teeth.
Nux moschata.-Toothache in children and women during pregnancy. Front
teeth especially. Stinging-tearing pains, worse in cold damp weather, and from wash-
ing, touching, or sucking the teeth. Better from application of warmth. First right
side, and then left.
Nux vom.-Men who use tobacco, coffee, and ardent spirits freely. Stinging in
decayed teeth; burning, stinging in a whole row of teeth; worse from cold things,
also coffee, wine; better from warm drinks, and from exercise, physical or mental.
Pulsatilla.—Fretful women and children. Drawing, throbbing, jerking tooth-
ache, with headache and earache, usually one side (left?); worse at night, from pick-
ing teeth, in a warm room or bed; when eating, but not from chewing; from cold
water, or warm food or drink, during pregnancy, and in women suffering from amen-
orrhoea. Better when walking in the open air.
Sanguinaria.-Toothache from picking the teeth (also Puls.), and in hollow
teeth when touched by food.
Staphisagria.-Easy and early decay of all the teeth; they are black, crum-
bling, and carious. Gnawing, drawing, tearing in the roots of decayed teeth, affecting
a whole row, and shooting into ear and temples. Worse from cold drinks, in the open
air, while eating, and from touch, but not from biting on them, and during the night
or towards morning.
Compare also:
DISEASES OF THE ORGANS OF DIGESTION.
511
Aconitum.-When caused by exposure to cold, dry wind. The pain is agoniz-
Useful
ing, and is accompanied by feverish action, with rush of blood to the head.
in children, and when Coffea has failed. When it fails, give Belladonna or Chamo-
milla.
Bryonia. The teeth are apparently sound. The pains extend to the head,
cheeks, and neck, especially while eating.
Calcarea carb.-During pregnancy and menstruation. Worse from cold
draught of air.
Causticum.-Stinging throbbing toothache from inhaling cold air.
side of the face, especially when lying upon it.
Cepa.-Characteristic catarrhal affections. First left, then right side.
Coca.-Said to prevent and to arrest caries.
In the left
Ignatia.-Resembles Nux vom., and often relieves when Nux fails.
Lachesis.-Pain referred to the gums, although the teeth are decayed and break
away. During damp weather. After the abuse of Mercury.
·
Mezereum.-Teeth sensitive to cold air and touch with the tongue. Sudden
paroxysms of pain, affecting the whole (left side) of the head, especially the temples
and facial bones.
Plantago.-Caries of teeth, with left-sided shooting pain. Red face. Worse
from walking in the cold air and from contact.
Phosphorus.-The teeth are black, and decay easily. Brought on by having
the hands in warm water. (Sepia.)
Sepia.-Toothache brought on by having the hands in warm or cold water. Char-
acteristic disturbances in women.
Sulphur.-Tearing toothache on the left side. Worse in the open air or from
the slightest draught; at night, from heat in bed, from washing with cold water.
Consult Ammon. carb., Apis, Clematis, Dulcamara, Hyoscyamus,
Kali carb., Magnesia phosph., Natrum sulph., Petroleum, Plumbum,
Rhus tox., Sabadilla, Silicea, Spigelia, Thuja, Zincum.
Dentists frequently have resort to the application of a mixture of
the tincture of iodine and carbolic acid by means of a pledget of cotton
saturated with the mixture, introduced into the cavity of the tooth;
the cavity is then filled with cotton, and the whole covered with a
resinous mixture which protects the diseased structures from coming
into contact with saliva or air. This treatment usually gives prompt
relief. In unmanageable cases, when dentists are convinced of the
wisdom and of their ability to save the tooth, Aconite or Morphine
are used in the same manner.
SWELLED FACE.
A non-specific swelling of one or both cheeks frequently accom-
panies or follows toothache. It is usually hard and pale, but some-
times it becomes red and erysipelatous. It is pretty sure to disap-
pear of its own accord within a few days, but in exceptional cases may
terminate in an abscess.
The following remedies prove useful:
Arnica.-Swelling is hard, stiff, sensitive, and pale; rarely red and hot.
Belladonna.-Swelling hot, red, erysipelatous.
Chamomilla.-Great fretfulness; swelling hard, hot, and red; almost as
marked as in belladonna.
512
A SYSTEM OF MEDICINE.
Hepar.-When the swelling begins to soften, but does not actually suppurate, or
the suppuration is very profuse. After Lachesis.
Lachesis.-Deep mahogany-red erysipelatous swelling of the (left) cheek. In-
tercurrently with Hepar.
Mercurius.-Hot, red swelling, like erysipelas. After Lachesis.
Pulsatilla.-When Chamomilla or Mercurius were taken for the toothache.
Sulphur.-When Arsenic, Belladonna, or Bryonia were given for the toothache.
Mostly pale swelling, sometimes erysipelatous.
DENTITION.
Synonyms.-Teething; (German) Zahnen; (French) Troubles de
la dentition.
Definition.-Physiologically speaking, dentition is the process of
development of the temporary teeth from the already ossified dental
sacs, and their eruption through the gums. As this development and
eruption is often attended by various morbid phenomena, the term
has attained a significance almost pathological, and the abnormalities.
observed coincident with this process are in most text-books con-
sidered under the title "dentition."
Etiology. Of the more remote but absolute causes which give
rise to diseases during dentition we have little positive knowledge,
although many surmises and ingenious theories are offered. A pure-
blooded, vigorous child will cut the whole twenty milk-teeth without
the occurrence of an abnormal symptom, save, perhaps, a slight eleva-
tion of temperature and some nightly restlessness.
The important changes which take place at this age in almost every
part of the organism, necessitating a state of marvellous activity, hence
excitability, deserve careful consideration. The brain is developing
more rapidly than at any other period of life. Its convolutions are
increasing in number and in size; the sulci are growing correspond-
ingly deeper; the brain substance itself is assuming more density and
firmness, and the distinction between its gray and white matter be-
comes more marked, while the yellow substance which served as a
boundary line between them is rapidly disappearing. In the intes-
tinal canal the follicular apparatus is undergoing a similarly marked
and rapid development. Leaving out of consideration the wonderful
functional activity of the brain, the constant exercise of every faculty
of the infant, we cannot be surprised that both the brain and the
bowels are easily irritated, thrown out of balance, and a morbid pro-
cess set up by a seemingly slight provocation.
Among the direct exciting causes of codentitional diseases, inap-
propriate clothing and improper food stand prominent. Already
made sensitive to atmospheric changes by the particularly rapid
changes going on in almost every direction, the young infant is con-
stantly exposed to danger from taking cold by the folly of parents who
think more of elegance of the baby's wardrobe than of its proper and
legitimate object. Dressed in light fabrics during the hot days of the
DISEASES OF THE ORGANS OF DIGESTION.
513
warm season, it is exposed to the cool air of evening without being
provided with additional clothing, and intelligent care is rarely taken
to dress the child in accordance with the needs of the hour rather
than with the customary dress of the season. The result is easily appre-
hended, and a series of slight catarrhal affections, often so insignificant
as to attract little, if any, attention, leads the way to a feverish condi-
tion which, during the process of teething, is sure to become an im-
portant factor in the development of grave ailments.
There exists also constant danger of committing errors in feeding
the infant which, in view of the sensitiveness of the digestive apparatus
at this time, must necessarily lead to those disorders of digestion which
so often form serious and unmanageable complications of " dentition,"
and which are fully described at another place.
Pathology. The pathology of the various affections which may
occur during dentition is not essentially different from that peculiar
to them at other times, and as treated elsewhere in this work. The
gums, however, present interesting and characteristic changes. They
swell, become tense and shiny, red, purple, even almost black in color;
if this exceedingly dark appearance continues for some length of time,
and the eruption of the teeth does not take place, the inflamed gum
undergoes a retrograde metamorphosis and becomes dense, hard,
whitish, or yellow-white, almost like cartilage. Sometimes the gums
become very hot, swollen, and extremely sensitive, the tooth presents.
a single point or corner through the gum, the edges of which ulcerate
and slough; this condition has been styled odontitis infantum.
Symptomatology.-A little swelling of the gums, some fever,
fretfulness and restlessness at night, mark the progress of a normal
dentition, each tooth in its development occasioning a manifestation
of such phenomena lasting about three days and nights. The symp-
toms of the various abnormalities of dentition will not vary for the
most part from those signs observed at other times, save that the fever
of dentition is extraordinarily irregular, now higher, now lower, with-
out any periodicity or apparent cause. If there be any characteristic,
it is a high early morning temperature, say 104° or 105° by eight
o'clock A.M.
Normally, dentition should begin not before the fourth month nor
later than the seventh, and should be completed during the first month.
of the third year. But it has been remarked that tuberculous and
syphilitic children cut their teeth early, while in rickety infants the
teeth are slow to appear.
The following abnormalities are those chiefly observed coincident
with teething: Nervous irritation, involving insomnia; febrile states;
intestinal catarrh; constipation; bronchial catarrh; skin affections,
especially eczema; eclampsia; retarded or difficult dentition; tuber-
cular meningitis.
VOL. I.-33
514
•
A SYSTEM OF MEDICINE.
Diagnosis.—The diagnosis of the various complications arising
during dentition depends upon the prompt recognition of their diag-
nostic symptoms, which are fully described under the various chapters
to which they properly belong. Grave cerebral disturbances are likely
to arise at this time, and the occurrence of any brain-symptom during
dentition must ever excite our anxious apprehension; and it behooves
the physician, especially in the case of scrofulous infants, with large
heads and open fontanelles, to be on his guard and to watch closely
for the first symptom indicating danger from this source.
Prognosis. The prognosis in diseases which are connected with
dentition, aside from their termination when appearing at any other
time, depends largely upon the vitality of the child, the intelligence
of the parents or nurses, the cleanliness and healthfulness of surround-
ings, upon the ease with which teething progresses, and, above all,
upon the diathesis of the patient. If the child is markedly scrofulous
or syphilitic, or gives evidence of a tubercular diathesis, conditions.
which in the healthy infant would not indicate especial danger would
so complicate the case that the prognosis must of necessity be guarded,
and, perhaps, decidedly unfavorable.
Treatment.-Careful attention to regimen is of the greatest im-
portance. The baby, before being fed heartily, should have a morn-
ing bath in tepid water, followed by gentle yet brisk friction. The
mouth and gums, after nursing or feeding, should be carefully wiped
with a soft cloth dipped in cold water. In warm weather the child
should live out of doors, playing, eating, and sleeping out of doors,
avoiding only exposure to inclement weather and to the extreme heat
of the sun. An abundance of sleep should be had, and due pains.
taken to secure it. Close attention to dress will amply repay for the
trouble taken by lessening the dangers arising from colds. The feet
and bowels should be particularly well covered when a tendency to
diarrhoea shows itself; during the cold season of the year the children
of the poor are habitually neglected, and thin and short stockings,
bare and cold legs, damp napkins, and an unprotected abdomen only
too often occasion long and stubborn sickness, and during the period
of teething cause serious illness when, with proper attention to these
details of dress, the entire process would have been completed with-
out difficulty. During the heated term, when severe diarrhoea so con-
stantly occurs in teething children, the importance of passive motion
from riding in a baby-carriage, or on a steamboat, anywhere in the
open air, cannot be overestimated. No matter how ill the little
patient, if properly dressed and comfortably placed in the carriage,
nothing but good will come from taking the child into the open air as
soon as bathed and dressed, and keeping it in passive motion through-
out the day; children, apparently ill beyond the hope of recovery,
revive perceptibly when thus treated; the intense restlessness is
DISEASES OF THE ORGANS OF DIGESTION.
515
greatly lessened, the condition of the bowels usually improves, and
a general and permanent change for the better is almost always ob-
served.
Nervous and sleepless children should be given absolute quiet of
surroundings, and their nurses should carefully abstain from worrying
and fretting. No loud noises should be tolerated; the prevalent belief
that babies do not mind noise is a great mistake. When feverish, the
little one should have, off and on, small quantities of cold drink,
preferably water, unless great gastric or intestinal irritation exists,
which is aggravated from taking cold drink. When diarrhoea exists,
the greatest pains must be taken to furnish the best of food—that is,
the food best borne. If breast-milk cannot be had, Imperial Granum,
Mellin's Food, some good brand of condensed milk, or any of the
various preparations likely to be thought of at such a time, may be
employed, always provided that it agrees; if it does, no change should
be made. Solid food is not to be used. Constipation can usually be
relieved by a small enema of soapsuds and sweet oil, lukewarm milk
or water. In skin affections the indicated remedy may be used
locally as well as internally. Cosmoline forms the best base for oint-
ments, and starch for powders.
A convulsed child should be put into a hot bath, near a fire when
the weather is cool; when the patient begins to relax, he is to be taken.
out of the bath, carefully but briskly rubbed, and, without being
dressed, wrapped in a warm flannel blanket. When fully restored to
consciousness, the child may be dressed. If the child remains in a
stupor and cannot swallow, a single drop of medicine may be safely
trusted on the tongue or between the teeth, and will serve its purpose
even when thus administered.
Many of the later authorities deprecate the old habit of lancing the
gums of teething children, save when the gums are very tense and of
a semi-cartilaginous consistency.
Therapeutics.-When sleeplessness and nervous irritability are the
most prominent symptoms, consult
1. Aconite, Belladonna, Chamomilla, Cina, Coffea,
2. Borax, Cypripedium, Kreasotum,
When fever is particularly marked, consult
1. Aconite, Gelsemium, Belladonna, Veratrum viride, Arsenic.
2. Chamomilla, Borax, Podophyllum, Nux vomica.
For intestinal catarrh, consult
1. Arsenicum, Calcarea phosph., Chamomilla, Colocynthis, Ipe-
cacuanha, Magnesia carbon., Mercurius, Podophyllum, Sul-
phur, Psoricum, Ferrum, Apium virus.
2. Calcarea carbon., Rheum, Jalapa, Cina, China, Kreasotum,
Sulphuric acid, Benzoic acid.
516
A SYSTEM OF MEDICINE.
For constipation, consult
1. Alumina, Bryonia, Calcarea carbon., Podophyllum.
2. Graphites, Kreasotum, Causticum, Nux vom., Silicea.
For bronchial catarrh, consult
1. Aconite, Ipecacuanha, Kali carbon., Tartar emet., Calcarea
carb., Dulcamara, Ferrum phosphor., Chamomilla.
2. Cina, Kreasotum, Cactus, Belladonna, Lycopodium, Rumex.
For skin affections, the following are to be studied:
a. Intertrigo. Borax, Graphites, Lycopodium, Mercurius, Sul-
phur, Rhus tox., Causticum, Petroleum, Hydrastis.
b. Eczema. Graphites, Sepia, Sulphur, Calcarea carb., Arsenicum,
Dulcamara, Hepar, Tellurium, Staphisagria.
c. Herpes. Sepia, Tellurium.
Convulsions call for
1. Belladonna, Gelsemium, Veratrum viride, Zincum met., Helle-
borus nig., Hyoscyamus, Cicuta, Cina, Cuprum met., Stra-
monium.
2. Aconite, Apium virus, Calcarea carbon.
For tardy dentition, consult
Calcarea carb., Calcarea phosph., Ferrum met., Phosphorus, Sul-
phur, Magnesia carbon., Magnesia muriat.
For full indications the reader is referred to the several chapters
treating upon the various disorders likely to occur during dentition;
the following brief and very general hints may also prove of service:
Aconite.-Characteristic restlessness. The child gnaws at its fist. Is most
nearly content while drinking or holding a cup of water.
Alumina.-Difficult voiding of even soft stool. Bottle-fed babies who are badly
constipated.
Apium virus.-Characteristic diarrhoea. The gums over the incipient teeth
are festered, showing little watery sacs. Brain-irritation, and starting during sleep
with a sharp cry. Red spots, like hives, here and there on the skin.
Arsenicum.-Characteristic gastric and diarrhoeic symptoms. Scaly, silver-
white eczema. Dry, shrivelled skin. Characteristic thirst and restlessness. The
blisters on the gum secrete a dark fluid (Apis, white).
Belladonna.-Symptoms of active congestion Of frequent use during the
occurrence of convulsions, when it is to be carefully compared with Veratrum viride
and Hyoscyamus.
Benzoic acid.-Diarrhoea of copious, grayish-white, watery stools, like dirty
soapsuds, excessively offensive, scenting the whole house. The urine is dark and
exceedingly offensive; it is sometimes retained, or passed involuntarily at night.
Borax.-Characteristic fear excited by a downward motion. Aphthæ of the
gums.
In nervous children it is often difficult to differentiate between Belladonna
and Borax; the former corresponds to the violently congestive or inflammatory type,
the latter to the purely functional group of disturbances.
Bryonia.—Dryness of lips and, usually, stools. The gums are pale, or light-
red, but hot and dry. Characteristic great thirst for cold water and aggravation from
motion.
Calcarea carb.-An excellent remedy for fair, fat, large children, with open
anterior fontanelles, and perspiration of the head during sleep. Large, chalky stools,
expelled with difficulty and pain (Hepar; Podophyllum). Loose, rattling cough.
Calcarea phosphorica.—Flabby, shrunken, emaciated children, with
DISEASES OF THE ORGANS OF DIGESTION.
517
open posterior fontanelles. The child does not learn, or forgets, to walk. Diarrhoea with
much flatus; green, thin, sometimes slimy stools, or fetid, containing pus. Rickets.
Causticum.-Dark-haired children with delicate skin. Intertrigo. Constipa-
tion. Tough stools, covered with mucus, looking as if greased. Tedious suppuration
of the gums.
Chamomilla. Of great use in nervous, excitable children who suffer from
the characteristic diarrhoea; the patient is not quiet unless constantly carried in the
arms; one cheek red, the other pale. Gums hot and tender. Fond of cold water.
Characteristic rotten-egg odor of the stools.
Cicuta virosa.-An excellent remedy for convulsions of teething children.
The jaws are firmly closed, as in lock-jaw; the limbs are relaxed and hanging down,
or stiffened and extended.
Cina.-Worm symptoms, and exceedingly sensitive, "touchy" mood of the
patient. Urine like milk. Convulsions, the child suddenly growing stiff, making a
noise as if water were poured from a bottle.
Cuprum met.-Convulsions. Vomiting of mucus (often green) before each
spasm. Convulsions begin in the muscles of the leg, and spread all over the body;
the child lies on its abdomen, and spasmodically thrusts the breech up.
Cypripedium.-Sleeplessness. The child is very lively, laughs and plays,
and will not go to sleep. A tendency to laugh constantly, at all times, is characteristic.
Ferrum phosph.-Useful in catarrh of the respiratory organs, the symptoms
resembling Aconite.
Helleborus.-White, jelly-like stools. Convulsions, with extreme coldness
and many brain-symptoms.
Hyoscyamus.-The symptoms resemble those of Belladonna. There is much
twitching of the muscles about the eye, and the remedy is of particular value if brain
irritation results from a fright.
Ignatia.-Well-known characteristics. The child is easily frightened, awakens
from sleep with piercing cries and violent trembling. Convulsions after fright or pun-
ishment, even when sleep intervenes, preceded by hasty drinking, frothing at the
mouth, and violent kicking, recurring daily, at the same hour.
Kreasotum.-Slow, difficult dentition. The child moans constantly while
asleep, or dozes with the eyes half-open, taking only short naps; better during the
day, but again worse at night. The gums are swollen, dark-red or purple, and seem
infiltrated with a dark ichor. The teeth turn black and decay as soon as cut. Dark-
brown, offensive diarrhoea.
Podophyllum.-Fever and sleeplessness from nervous irritability; the child
is drowsing, with eyes half closed, moaning and whining; rolling of the head from
side to side (Apis, boring of the head into pillows; Stramonium, sudden, quick raising
of the head from the pillows, dropping it again as suddenly). Characteristic diarrhoea.
The child gags; there is no stomach-effort; the mouth alone seems engaged in it.
Morning aggravations. Prolapsus recti.
Silicea.-Children who have large heads with open sutures, and who are very
large and full in the abdomen. Tardy dentition, the gums being sensitive and blis-
tered. Fetor of the feet, which is not removed by washing.
Stannum.-This remedy is often very useful when Cina seems indicated but
fails to relieve. During sleep the child moans and seems to supplicate in a timid
manner. Pains in stomach and bowels are relieved by lying with the abdomen pressed
against some hard substance.
Staphisagria.-The patient is very sensitive to physical and mental impres-
sions. Pot-bellied children who have much colic and rectal tenesmus, not relieved
by free evacuations. The gums look whitish and are tender; the teeth are dark in
streaks.
Sulphuric acid.-Aphthous condition of the mouth and gums. Stools of
bright, yellow mucus, stringy or as if chopped.
Tellurium.-Ring-worms all over, more distinct on the legs. After Sepia.
Veratrum viride.-The child trembles as if frightened and on the verge of
a spasm. Convulsions with opisthotonos in anæmic children, after diarrhoea. Irrita-
tive fever, with quick, hard, bounding pulse; when congestion threatens the brain,
chest, spine, or stomach.
518
A SYSTEM OF MEDICINE.
Zincum.-Convulsions in anæmic, pale children, who are cross during the day
and restless at night, with jerking and twitching of the feet and muscles generally,
especially on the right side. Nightly fever.
DISEASES OF THE TONGUE.
BY CLARENCE M. CONANT, M.D.
PARALYSIS OF THE TONGUE.
Synonym.-Glossoplegia.
Definition.-Partial or complete loss of power to move the tongue,
with or without atrophy of its substance.
Etiology. Since the hypoglossal nerve is the motor of the tongue
and its subjacent muscles, we find glossoplegia arising from the pres-
sure upon it of tumors and syphilitic growths, or of the exudation of
meningitis and of caries of the cervical vertebræ. A lesion of the nerve
itself, independent of any discoverable cause, may occasion paralysis
of the tongue.
Pathology. In glossoplegia the locality of the lesion in the hypo-
glossal nerve is interesting and diagnostic. Thus, unilateral paralysis
indicates pressure upon, or disease of, the motor tract above the nu-
cleus (the nucleus being rarely affected), or of the filaments of the
nerve either within or without the medulla oblongata. Bilateral par-
alysis mostly arises from disease of the nucleus or its immediate neigh-
borhood. The pathological process consists in inflammation, hyper-
æmia, and thickening of the walls of the vessels and round cells, with
consequent atrophy of the gray nuclei. In glasso-labio-laryngeal or
bulbar paralysis these lesions extend from the nuclei of the hypo-
glossal to the gray matter whence originate the fibres of the pneumo-
gastric, the glosso-pharyngeal, the abducens, the trigeminus, the
seventh pair, and the spinal accessory.
Symptoms. In unilateral paralysis the tongue is observed to lie
naturally in the mouth, save that the root on the affected side is ele-
vated above the rest of the tongue, nor can the tongue be moved to
the paralyzed side, while to the unaffected side it is freely movable.
When protruded, it is curved about toward the affected side; articu-
lation remains normal, except that the pronunciation of the labials is
difficult; deglutition is not impaired, or at worst is performed rather
awkwardly.
In bilateral paralysis the tongue lies helpless, flat, and flabby in the
mouth; it cannot be protruded, or, at best, it is slightly raised and
pressed against the under teeth; articulation is lost, but not always
phonation, the production of sounds being possible, unless the larynx ·
is also paralyzed; mastication and deglutition are performed with dif-
ficulty; the sense of taste is impaired in some cases, but never quite
DISEASES OF THE ORGANS OF DIGESTION.
519
lost, unless extreme atrophy be present, a condition of somewhat rare
occurrence.
Diagnosis. Paralysis of the tongue may accompany various par-
alytic and brain affections; it is then merely a symptom. In an in-
dependent unilateral paralysis of the tongue there is sometimes found
paralytic weakness of the same side of the whole body, or perhaps only
of the corresponding half of the palate and vocal cords. Bilateral
glossoplegia is usually associated with atrophy of the tongue and par-
alysis of the lips and throat.-The prognosis is always unfavorable.
Treatment.-Baryta carb.-Paralysis of the tongue, with loss of speech.
Fleshy old people, or dwarfish, scrofulous children.
Causticum.-Paralysis of the tongue, larynx, and even lips. Speech is stutter-
ing, difficult, indistinct, or lost entirely; distortion of the mouth and tongue when talk-
ing, or attempting to do so.
Hyoscyamus.-Speech embarrassed; tongue protruded and drawn in with
difficulty; useful in old men and drunkards.
Nux moschata.-The child, though old enough, cannot talk; it acts as if it
were difficult to move the tongue (Natr. mur.); anæmia and infantile marasmus. Old
people, especially women.
Opium.—Paralysis of the tongue, with difficult articulation. In children, old
people and drunkards.
Plumbum.-Tongue heavy or paralyzed.
Compare also Aconite, Arsenicum, Belladonna, Graphites, Lachesis,
Natrum muriat., and Stramonium.
•
Tongue heavy.-Anacardium, Belladonna, Carbo veg., Colchicum,
Lycopodium, Muriatic acid, Natrum mur., Plumbum.
Tongue moved with difficulty.—Anacardium, Belladonna, Calcarea
carb., Lycopodium, Natrum mur., Nux mos.
Tongue stiff.-Borax, Colchicum, Euphrasia, Lachesis, Natrum mu-
riaticum.
INFLAMMATION OF THE TONGUE.
Synonym.-Glossitis.
Definition. An inflammatory infiltration of a circumscribed part
of the tongue, or of the entire organ, characterized by swelling, tender-
ness, and pain.
History. When calomel was universally and profusely adminis-
tered, mercurial glossitis was a frequent accompaniment of salivation;
but it is now of comparatively rare occurrence.
Etiology.-Glossitis is sometimes epidemic; sporadic cases follow
a chill, just like pneumonia or influenza; but we do not know why
the tongue is attacked in preference to other organs. Mercury and
other corrosive chemicals may cause glossitis by their direct action
upon the tongue, or inflammation may arise as the result of injuries
from the bites and stings of insects, and from septic poisoning, as in
anthrax. Glossitis is occasionally a symptom arising during the
course of other diseases.
520
A SYSTEM OF MEDICINE.
Pathology.-Glossitis is an inflammatory infiltration of the inter-
stitial connective tissue of the tongue. Usually, this process ends in
resolution, but sometimes abscesses are formed and, more rarely, the
connective tissue becomes largely increased and indurated, and remains
so permanently, resulting in an acquired hypertrophy of the tongue.
In the height of the inflammation the muscular fibres are swollen,
friable, and exsanguinated.
Symptomatology.-The most prominent and important symp-
tom is rapid and excessive swelling of the tongue. Sometimes two
days may suffice to so increase it that the mouth must be kept open.
to allow it a partial protrusion. Swallowing and breathing are per-
formed with difficulty. The patient suffers paroxysms of asphyxia,
becomes cyanotic, and suffocates, unless the pressure occasioned by the
swollen tongue is promptly relieved.
The submaxillary and cervical glands are often swollen, especially
when septicemia prevails. The patient complains of severe pains ex-
tending to the ears and throat. The disease runs a rapid course, and
ends by complete resolution or partial subsidence of the swelling, leav-
ing a chronic hypertrophy. In less favorable cases death ensues from
suffocation, or abscesses form and burst, or, in case of mercurial poi-
soning, gangrene appears and portions of the tongue slough off.
A partial glossitis commences as a small, painful swelling, like a
kernel, on the back part of the tongue, which forms slowly, suppurates,
discharges and heals without exciting any marked constitutional symp-
toms.
Diagnosis.-Universal glossitis is recognized promptly and easily.
Partial glossitis might be mistaken for a cancerous or syphilitic tumor,
but will be readily distinguished by its bland nature and the compara-
tive rapidity of its development.
Prognosis. In traumatic, sporadic and epidemic cases the prog-
nosis is generally favorable. In mercurial poisoning it is grave. In
septic cases it is very unfavorable.
Treatment.—Apis.—Stinging, burning pain in the tongue; blisters or vesicles
along its edge or on its dorsum.
Arsenicum.-Violent burning pain in the tongue; swelling about the root of
the tongue externally and internally. Gangrene of the tongue. Spots on it which burn
like fire.
Belladonna.-Tongue much swollen and inflamed; papillæ deep red, edges and
tip pale red.
Cantharides.-Tongue swollen and thickly coated; the base is partly covered
with blisters and partly excoriated.
Conium.—Tongue swollen, stiff and painful; chronic indurations after acute in-
flammation.
Cuprum.-Chronic glossitis; tongue dry and rough, papille enlarged.
Lachesis.-Tongue swollen, coated white; papillæ enlarged; dry, red and
cracked on the tip; mapped, dry, black and stiff; blisters about the tip of the tongue;
it trembles, or catches on the teeth, when protruded.
Lycopodium.-Tongue distended, giving the patient a silly expression; pain-
ful and swollen in places; tubercles; vesicles on the tip of the tongue.
DISEASES OF THE ORGANS OF DIGESTION.
521
Mercurius. Tongue swollen, flabby, imprinted by the teeth; inflamed, indu-
rated or suppurating, with pricking pains. Tongue swollen, stiff, with ptyalism, pa-
pillæ elevated, strawberry-like (Mercurius cor.).
Plumbum.-Tongue inflamed, swollen, hurts as if bitten.
Glossitis from the sting of an insect: Camphora or Natrum mur.
Glossitis from abuse of Mercury: Hepar. or Nitric acid. Glossitis leav-
ing chronic indurations: Calcarea carb., Carbo an., Conium, Hepar,
Lycopodium, Mezereum, Silicea, Sulphur.
Whenever immediate relief must be had, free scarification of the
tongue, or the application of leeches, may become a necessity. If pus
has formed in any part of the tongue, its evacuation will afford great
relief.
CANCER OF THE TONGUE.
Definition. A swelling or ulceration on the tongue exhibiting the
characteristics of cancer.
Etiology.-Cancer of the tongue is rarely seen in persons under
forty years of age, and is twice as common in men as in women (W.
Fairlie Clark). As the epithelioma more often arises from the edge of
the tongue, it has been thought that the sharp point of a carious or
broken tooth is the provoking cause.
Pathology.—An epithelioma begins in a limited infiltration of the
edge of the tongue, forming a hard tumor which soon bursts into an
excavated or flat ulcer with infiltrated edges. This ulcer is very de-
structive of the surrounding tissues, and by the sympathy of the lym-
phatics, so characteristic to cancer, secondary epitheliomatous forma-
tions shortly appear in the submaxillary and even cervical glands.
Scirrhous formations of the tongue are rare, but when they occur the
infiltration is more general and less circumscribed than that of the epi-
theliomata, so that the exact limits and dimensions of the tumor are
recognized with greater difficulty. There is a proliferation, hardening
and contraction of the connective tissue which occasions a shrunken
appearance of the tongue. Recent parts of a scirrhus show epithelial
cells and stroma in abundance, while in older portions the cells have
disappeared for the most part and we find only a dense connective
tissue. This appearance is occasioned by fatty degeneration.
Encephaloid or soft cancer of the tongue is of such rare occurrence
that its discussion may be omitted.
Symptomatology.-The varieties of cancerous degeneration in
the tongue present no difference in their earlier symptoms. A scratch
or crack or abrasion is noticed in the side of the tongue, about midway
from the tip to the root; or a small, hard, tender lump is observed in the
side of the tongue, either protruding from its substance or buried in it.
This scratch or lump may result from some local injury or previous.
lesion, or it may arise without any known cause. Lancinating, dart-
ing, boring, burning pains soon appear, radiating from the diseased
522
A SYSTEM OF MEDICICE.
spot into the head, ears and throat. These pains are aggravated at
night, and are often so agonizing as to drive the patient to contemplate
suicide. Salivation causes incessant spitting; the whole base of the
tongue becomes thickened, infiltrated and immovable, and the sore or
node develops into a foul, ragged, excoriated ulcer. This ulcer declares
its true character by its continuous eating-away both along the surface
and into the substance of the tongue, by its raised edges, from which
a milky, viscid fluid (cancer-juice) is readily expressed, by its hard,
uneven, lardaceous bottom, and by the characteristic pains. The ad-
jacent glands, both salivary and lymphatic, become swollen and tender.
As the ulceration proceeds, portions of the tongue slough away, cere-
bral circulation is unbalanced, and headaches and vertigo follow.
Owing to the helpless condition of the tongue, eating is agony, and
emaciation and prostration are inevitable. Stagnation of the circula-
tion in long-lasting cases may occasion oedema glottidis, bronchitis, or
even pneumonia (W. Fairlie Clark). The disease lasts from one to
three years, the average duration being fifty-seven weeks.
Cancer of the tongue is almost invariably epithelioma, either super-
ficial or deep. The former, which is probably not really cancerous, is
known by a little itching and burning, raised papillæ, or even a slight
superficial ulceration; while the deep variety presents those graver
symptoms above enumerated. Scirrhus or encephaloid are rarely seen
upon the tongue.
Diagnosis. In early stages the diagnosis between cancerous and
syphilitic affections of the tongue is extremely difficult. Gummata,
however, develop rapidly into ulcerations, whereas the cancerous de-
generation is slow, and, when advanced to ulceration, is marked by its
unmistakable characteristics.
Prognosis. The outlook is always unfavorable, excepting in cases
of the so-called superficial epitheliomata. When these heal perma-
nently and kindly, we have pretty strong proof that they were not
really cancerous.
Treatment.-Arsenicum album.—Violent burning on the tongue; swelling
about the root of the tongue, internally and externally. Burning, lancinating pains;
emaciation, restlessness, anguish, characteristic thirst.
Arsenicum iodat. resembles Arsenicum album closely. Is preferred to the
former when a painful diarrhoea exists.
Gallium aparine.—Nodulated tumors or cancerous ulcers on the tongue.
Dropsical symptoms.
Hydrastis canadensis.—Tongue swollen, saliva increased, thick and tena-
cious; erosions.
Lachesis.—Bad odor from the mouth; saliva increased and tenacious; tongue
dry, black and stiff.
Nitric acid.-Deep, irregular ulcers on the edge of the tongue, with secretion
of tough, ropy mucus, cadaverous odor from the mouth, and fetid, acrid, bloody saliva.
Tumor in the mouth.
Silicea.-Cancerous ulcer on the right edge of the tongue, eating into the tongue,
and discharging much pus. One-sided swelling of the tongue.
DISEASES OF THE ORGANS OF DIGESTION.
523
Compare also Carbo an., Carbo veg., Causticum, Conium, and Phyto-
lacca.
SIMPLE ULCERATION OF THE TONGUE.
Definition. A suppurative degeneration of circumscribed parts of
the tongue, of non-specific origin, and marked by the characteristics of
a bland ulceration.
Etiology. Simple ulceration of the tongue is caused by a vitiated
digestion, although its exciting cause may seem to be a cold or a
wound made with the teeth, or some sharp instrument, or even by an
accumulation of tartar on the teeth.
Pathology.-Joseph Coats aptly styles ulceration "molecular ne-
crosis." By it we understand a gradual loss of vitality of the affected
part, a breaking down of its structure, and the conversion of the ele-
ments of that structure into the inflammatory exudation.
Symptomatology.-In badly fed children, or in high livers, or in
chronic dyspeptics, a small, shallow ulcer is often seen on the sides,
upper surface, or tip of the tongue, and especially on the frænum
linguæ. The ulcers are surrounded by a halo of inflammation, are
flat, and are covered by a yellow slough. They are exquisitely tender
when touched or when the tongue is moved; sometimes the breath of
the patient and the discharge from the ulcer are very offensive, and the
sublingual and submaxillary glands not infrequently sympathize.
Diagnosis. The simple or dyspeptic ulcer is known by the nega-
tive evidence of the blandness of its nature and of the absence of all
constitutional symptoms, with prominent gastric disturbances, distin-
guishing it from all other ulcerations of the mouth.
Treatment.-Arsenicum.-Violent burning in small pit-like ulcers on the
tongue. Aphthous ulcers..
Baptisia.—Tongue cracked, sore and ulcerated; fetid odor from the mouth.
Hydrastis. Tongue dark-red, ulcerated, and feels as if raw, burnt, or scalded.
Aphthous ulcers.
Mercurius.-One of the best remedies for this condition. Tongue inflamed,
indurated, or suppurating; pricking pains. Burning, aphthous ulcers (especially the
red Iodide).
Also, Aloes.-Yellow ulcers on the tongue.
Apis.-Tongue cracked, sore, ulcerated, or covered with vesicles.
Aurum met.-Aphthæ and ulcers on the tongue.
Benzoic acid.-Extensive ulceration of the tongue, with deeply chapped fun-
goid surface.
Borax.-Red blisters (?) on the tongue, as if the surface were eroded, with pain
from every motion of the tongue, or from being touched.
Capsicum.-Flat, sensitive, spreading ulcer, with a lardaceous centre, on the
tongue.
Fluoric acid.-Tongue deeply and widely fissured in all directions, with a
large deep, phagedenic ulcer in the centre.
Graphites.—Whitish, painful ulcer on the under side of the tongue.
Hamamelis.-Tongue feels as if scalded; blisters on its sides, and cankers near
the tip.
524
A SYSTEM OF MEDICINE.
Kali bichrom.-Deep ulcer on the edge of the tongue.
Lycopodium.-Ulcers on and under the tongue.
Muriatic acid.—Tongue sore, bluish; contains deep ulcers, with black bases,
and vesicles.
Nitric acid.-Deep, irregular-shaped ulcers on the edge of the tongue; ulcera-
tion of tongue, with tough, ropy mucus.
Phytolacca.-Small ulcers on the tongue, like those produced by mercury.
DISEASES OF THE SALIVARY GLANDS AND THEIR DUCTS.
BY CLARENCE M. CONANT, M.D.
RANULA.
Synonyms.-(French) Grenouillette; (German) Ranula or Frö-
schleingeschwulst.
Definition. A cystic tumor lying beneath the tongue.
History. The exact nature of ranula has been the objective point.
of much investigation, speculation, and discussion. It was long
thought that the obstruction of Wharton's duct occasioned the de-
velopment of the sublingual gland into a cystic tumor. But the ob-
servations of Recklinghausen show that the initial cause is purely
mechanical, and not at all pathological. An inflammatory action
closing the orifice of the duct, it becomes distended by the constantly
accumulating secretion poured into it from the still intact and active
gland, so that the cyst-walls are not the gland-walls, but the walls of
the duct. It will thus be seen that persistence and not the destruction
of the gland is an essential condition in the formation of ranula. Un-
doubtedly, the bona fide ranula is, therefore, of glandular origin; and
it cannot be denied that the pathologists and nosologists have con-
fused nomenclature in including under that term also cysts arising
(from unknown causes) in the sublingual areolar spaces, and in the
bursa between the genio-hyo-glossi muscles.
Etiology.-A ranula, then, may be produced by any cause which
occludes the orifices of the ducts leading from the sublingual and sub-
maxillary glands; such a cause is, commonly, an inflammatory pro-
cess in the mouth; or the formation of calcareous concretions upon
the margins of the duct delta or impacted in the duct, or a salivary
calculus. Cystic tumors, entirely unconnected with the glandular ap-
paratus, and situated under the tongue, or even protuberant between
the tongue and the jaw in the upper part of the neck, are also styled
ranulas.
Pathology.-Ranula is a retention-cyst; that is to say, it is the di-
lated duct of either the submaxillary, sublingual, or mucous glands,
distended with the accumulated and retained secretion from the gland.
The stagnant secretion becomes inspissated and almost jelly-like; it
resembles albumen, has no salivary reaction, and under the micro-
DISEASES OF THE ORGANS OF DIGESTION.
525
scope shows tessellated and globular epithelial cells and cholesterine
crystals. Where the cyst is of idiopathic origin, so to speak, a seba-
ceous cyst, the contents are a dirty-white, often offensive, putty-like
substance of greater consistency than the semi-fluid contents of the
retention cysts, but, like them, made up of epithelium, cholesterine,
and oil. These sebaceous cysts are certainly in a sense retention cysts
likewise, but their contents and mode of growth present greater ab-
normalities than the class first mentioned.
Symptomatology.-Ranula is chiefly a disease of childhood. A
round or ovoid, painless, semi-pellucid swelling is found in front of,
and under, the tongue. Inspection shows the tumor to be a cyst which
contains a fluid, jelly-like or pasty substance; the former indicates a
very recent formation, the second an older tumor, and the last a seba-
ceous cyst of non-glandular origin. Should the tumor remain on the
floor of the mouth, as is the habit of a tumor of glandular origin, and
attain any considerable size, the various uses of the tongue are seriously
impeded, and the front lower teeth may be displaced. If the swelling
protrudes beneath the jaw in the neck, deglutition, and even respira-
tion, may become embarrassed; in such cases it is safe to infer that
the tumor is of sebaceous origin, and not a retention cyst. The reten-
tion cyst is usually rapidly developed as the capacity of the duct is
limited, while the sebaceous cyst is likely to be more tedious in its
growth. W. Fairlie Clarke thinks that "the majority of cases of ran-
ula are unconnected with the salivary glands."
Treatment. The treatment of ranula by internal medication is
unsatisfactory. The following remedies have been recommended:
Thuja, Calcarea carb., Mercurius sol., Belladonna, Mezereum, Nitric
acid, Fluoric acid.
Surgical treatment is somewhat more satisfactory. The cyst is
opened from the mouth, emptied of its contents, and filled with lint.
The use of Iodine, preferably a solution of the crystals in water, in-
jected into the cyst, offers advantages which deserve consideration.
DISEASES OF THE TONSILS.
BY CLARENCE M. CONANT, M.D.
TONSILLITIS.
Synonyms.-Quinsy, Cynanche tonsillaris, Amygdalitis, Angina
tonsillaris.
Definition.-Inflammation of either superficial or deep structures.
of the tonsils, tending to abscess and ulceration.
Etiology.-Tonsillitis chiefly affects young persons. It occurs.
most frequently in the damp weather of spring and autumn, or after
526
A SYSTEM OF MEDICINE.
a sudden fall in the temperature; exposure to severe cold winds or
getting wet is a frequent cause. One attack predisposes to another.
Pathology.-The swollen tonsil in a parenchymatous amygdalitis
consists of an inflammatory infiltration of the lymphatic follicles. Mr.
Joseph Coats thinks that suppuration rarely results when the tonsils
alone are inflamed and the adjacent structures unaffected. A follicu-
lar catarrh of the tonsils is sometimes coexistent with a similar affec-
tion of the pharynx. A thin, or more often thick, yellowish-white,
cheesy substance is exuded upon the surface of the tonsil, either in
patches or covering the whole gland. This exudation is sometimes
mistaken for that of diphtheritis, but is readily distinguished by its
want of all organization as a true membrane, and by its easy removal.
When the gland is seen honeycombed, and when its mucous covering
is otherwise intact, sometimes an abscess is formed at some point in
the connective tissue surrounding the tonsil; this is appropriately
styled a peri-tonsillar abscess, or, to coin a word, peri-tonsillitis.
Symptomatology.-In a case of simple catarrh of the mucous
membrane covering the tonsils, or of their follicular apparatus, the
symptoms are few and not severe. A complaint of sore throat will lead to
an inspection of the fauces, when the tonsils and palatine arches are seen
swollen and inflamed, and a vitiated secretion, as described, is observed
upon these glands. A few days will suffice to effect a spontaneous
evacuation of the supercharged follicles, or more rarely the inflamma-
tion assumes a sub-acute character, and the exudation degenerates into
a hard and cheesy, or even calcareous substance, which is gradually
worked out of the tonsil, when the latter slowly resumes a normal
state.
Parenchymatous tonsillitis, or peri-tonsillar abscess (the angina
gravior of William Aitken), is a much more serious disorder, whose
onslaught is marked with rigors and fever. The throat becomes sore,
deglutition difficult, and even talking, moving the tongue or head, is
quite painful. In small children convulsions sometimes are the first
morbid manifestation. Severe pains in the throat, which extend along
the Eustachian tube into the ear, down into the neck, or up to the
head, augment the distress.
If the tonsils are much swollen, paroxysms of suffocation alarm the
patient, especially when lying down, and he sits in a chair, day and
night. The fever is now intense, temperature reaching 105° F., and
the pulse running from 100 to 110, with morning remissions and even-
ing aggravations. The patient refuses all food, but craves drink,
which he cannot swallow, and frequently he is exhausted and delirious.
In eight to ten days (often during sleep) the abscess suddenly breaks,
and a complete remission of all the symptoms follows.
If the throat be inspected during the height of the disease, the ton-
sils will be seen scarlet-red and swollen so as to fill the whole fauces,
C
DISEASES OF THE ORGANS OF DIGESTION.
527
of which any part visible will be observed to be highly inflamed. This
inspection cannot be had in every case, as the patient cannot always
open the mouth sufficiently to permit it. A peculiar, thick, guttural,
or possibly nasal quality of the voice in cases of angina shows that the
tonsils are swollen. The following varieties are distinguished: simple
catarrhal tonsillitis, follicular tonsillitis, parenchymatous tonsillitis,
peri-tonsillar abscess.
Diagnosis. An inspection of the throat determines the diagnosis.
When inspection is impossible, we must be guided by the other symp-
toms. The prognosis, with rare exceptions, is favorable.
Treatment. The diet should be liquid or semi-solid, and light.
Hot milk, beef tea and mutton broth are excellent; oatmeal porridge,
blanc mange, or any easily swallowed and nourishing food may be
allowed.
Apis.—Tonsils swollen, bright red; stinging pains in them when swallowing;
deep ulcers on the tonsils, surrounded by an erysipelatous cedematous halo. Throat
swollen inside and outside; breathing, talking, and swallowing difficult. The voice is
hoarse and guttural. Absence of thirst.
Baryta carb.-Tonsillitis after a light cold or suppressed foot-sweat. Tonsils
tend to suppurate, especially the right tonsil.
Belladonna.-The swelling is bright red; the neck is swollen, stiff, and tender
externally. Rapidly forming aphthous ulcers on the tonsils. Intense congestion,
headache, and even delirium; preference for the right side.
Bromium.-Constant pain in the throat; swallowing difficult, of fluids more so
than of solids; after measles.
Cantharides.-Aphthous ulcers, covered with a white, adherent crust on the
right tonsil. Whole throat swollen, and liquids swallowed with extreme difficulty.
Cuprum met.-Tonsils and whole throat inflamed; dull pain in the left tonsil.
As Cuprum acts especially upon cellular inflammations, it should be carefully considered
in the treatment of peri-tonsillar abscess.
Hepar sulph. calc.-Swelling of the tonsils and glands of the neck. Sensa-
tion, when swallowing, as if a fish-bone or splinter were sticking in the throat. After
the use of mercury, when suppuration is inevitable, but delayed.
Ignatia.—Inflamed, hard swollen tonsils, with small ulcers. "In follicular ton-
sillitis almost specific." (Raue.)
Lachesis.-Pain, soreness and swelling of the left tonsil, with a tendency to ex-
tend to the right side; inability to swallow, with pain shooting into the ear (left) when
the attempt is made; aggravation from hot drinks; fluids are swallowed with more
difficulty than solids, and are returned through the nose. Excessive tenderness of the
throat to external pressure. Peri-tonsillar abscess.
Lycopodium.-Swelling and suppuration of the tonsils, extending from right
to left.
Mercurius sol.-Tonsils dark red, studded with ulcers; stinging pains in the
throat.
Mercur. iodat.-Easily detached patches (pseudo-membrane) on the right
tonsil; thick, bright yellow coating on the base of the tongue; salivary glands
swollen.
Mercurius biniod.-Left tonsil swollen; fauces dark red; diphtheritic
patches; submaxillary glands painfully enlarged; follows well after Belladonna.
Phytolacca.-Tonsils large, bluish, ulcerated; throat feels dry, rough, burn-
ing, smarting, as if puckered up with an astringent; pus watery, fetid, ichorous, defi-
cient.
Plumbum met.-Tonsils inflamed and covered with small painful abscesses;
left side.
528
A SYSTEM OF MEDICINE.
Silicea.-Tonsils swollen, inflamed; and abscesses form, which refuse to heal;
especially on the left side; fistulous ulcerations. Peri-tonsillar abscess.
Sulphur.—Tonsillitis, first on the right side, then on the left. Scrofulous dia-
thesis.
Compare Ammon. mur., Benzoic ac., Calcarea carb., Psorinum, Ran-
unculus sceler.
Poultices around the throat, so soon as resolution becomes impos-
sible, hasten the climax. Earlier, inhalation of steam from water
medicated with the appropriate remedy is always grateful, and often
efficient. A gargle of warm milk and water is very useful, and often
indispensable after the abscess has burst and is discharging. Should
the discharge be offensive, a weak solution of Permanganate of potash,
or Platt's Chlorides, will be of service.
HYPERTROPHY OF THE TONSILS.
Synonyms.-Enlarged tonsils, Chronic tonsillitis.
Definition.-A low grade of painless inflammation occasioning and
accompanying abnormally large tonsils.
Etiology.-Chronic hypertrophy of the tonsils is frequently an
hereditary symptom of scrofulosis. In the adult, its occurrence de-
pends upon frequent and severe attacks of acute tonsillitis during
childhood.
Pathology. The chronically enlarged tonsil consists of a true hy-
pertrophy of its lymphatic follicles, and in many cases of a prolifera-
tion of the inter-follicular connective tissue. The increase of the former
tissue preserves to the enlarged gland an approximately normal density,
so that it is not usually found very hard. When the gland is indu-
rated as well as enlarged, the connective tissue has become hardened
and thickened by a low grade of inflammation, which, in turn, arises
from repeated attacks of acute angina which have closed and distended
the follicles. This condition has been styled "scirrhus of the tonsil "
(Claude Muirhead). That the scrofulous habit, rather than the re-
peated attacks of acute inflammation, is the chief cause of tonsillar
hypertrophy appears from the fact that the greatest degrees of enlarge-
ment are usually seen in children who have never suffered an acute
tonsillitis. Thus it follows that in the enlarged but soft tonsil we can
observe evidence of the scrofulous diathesis; the indurated tonsil
usually affords a history of previous quinsies.
Symptomatology.-Among the first signs of enlarged tonsils are
commonly noticed a peculiar silly expression of countenance, occa-
sioned by the mouth being continually kept partly open. This open
mouth may be observed both day and night, and is an effort to facili-
tate the respiration which is impeded in the nasal passages by the
partial closure of the posterior nares. For the same reason, the patient
snores loudly and continuously when asleep. The peculiar quality of
DISEASES OF THE ORGANS OF DIGESTION.
529
voice to which allusion was made under Acute Tonsillitis is equally
pronounced in the chronic form, the enunciation being thick, guttural,
and almost nasal. When the glands are very large, the patient com-
plains of a sense of a lump, or a fulness, in the throat, and is some-
times quite deaf. All these symptoms are greatly intensified whenever
the patient has an acute attack of catarrh or angina; and persons suf-
fering from them are peculiarly susceptible to all throat affections, and
when seized with any disease of which angina is a prominent symp-
tom (as diphtheria or scarlatina), suffer its extreme penalties.
Prognosis. Hypertrophy of the tonsils is removed slowly under
the most favorable conditions, and the enlarged gland rarely returns
to an absolutely normal size.
Treatment.-Baryta carb. or Baryta iodat.-Chronic induration of the
tonsils; sensation as of a plug in the throat; difficulty of swallowing solids.
Baryta mur.-Chronic hoarseness from enlarged indurated tonsils. Difficulty
of swallowing; mercurial breath.
Calcarea carb.-Characteristic constitutional symptoms.
Calcarea iod.-Chronic tonsillitis, with disposition to laryngeal catarrhs.
Calcarea phos. and Sulphur.-Recommended as indicated by character-
istic constitutional symptoms.
Hepar s. c.-Chronic tonsillitis with hardness of hearing; sensation of a splinter
or fish-bone in the throat.
Ignatia.-Tonsil indurated, not inflamed.
Lycopodium.-Tonsils enlarged, indurated, and covered with many small
ulcers.
Mercurius biniod.—Affects the left side chiefly; recommended by Edmunds
as the specific for chronic tonsillitis.
Consult also Kali bichrom., Kali iodat., Phosphorus, Phytolacca,
Psorinum, and Sulphur.
DISEASES OF THE PHARYNX.
BY W. T. LAIRD, M.D.
ACUTE CATARRHAL SORE THROAT.
Synonyms. Common sore throat, Superficial sore throat, Inflam-
matory sore throat, Erythematous sore throat, Rheumatic sore throat,
Pharyngitis simplex, Pharyngitis catarrhalis, Angina erythematosa,
Angina catarrhalis, etc.
This affection consists of an acute erythematous inflammation of the
mucous membrane of the pharynx, tonsils, and soft palate. The in-
flammatory process may be either circumscribed or diffuse; in the
majority of cases, one side of the throat is more prominently affected
than the other.
Etiology. The disease occurs most frequently in children and
adolescents, but no period of life can claim entire immunity from its
VOL. I.-34
530
A SYSTEM OF MEDICINE.
attacks. It is most prevalent during cold and inclement weather. It
is usually sporadic, but under certain peculiar atmospheric conditions,
the exact nature of which has not yet been ascertained, has been known
to occur as an epidemic. In the victims of malarial poisoning it some-
times manifests a periodical tendency, and in rheumatic patients it
often precedes an outbreak of acute articular rheumatism. The sus-
ceptibility to sore throat varies greatly in different individuals; some
rarely have an attack, while others contract the disease whenever the
weather changes. Persons debilitated by scrofulosis, syphilis, or the
abuse of mercury, are peculiarly liable to this affection. Sedentary
habits, defective ventilation, impure water, and bad food may also act
as remote causes. In fact, anything which tends to depress the vital
powers and renders the body unduly sensitive to atmospheric vicissi-
tudes, may aid indirectly in the production of this malady. The im-
mediate exciting cause is usually exposure to cold and dampness.
Acute catarrhal sore throat may also be induced secondarily by the
extension of inflammatory affections of the nose, larynx, or buccal.
cavity, by gastric catarrh or by measles, scarlatina, small-pox, typhoid
fever, pneumonia, gout, tuberculosis, and various other acute and
chronic diseases.
Anatomical Characters.-On inspection of the fauces, the mu-
cous membrane covering the pharynx, tonsils, and soft palate is seen
to be congested, swollen, and often oedematous. Its color varies from
a bright red to a dark or even livid hue. The follicles are generally
enlarged, and there is a more or less profuse, muco-purulent, tenacious
secretion, which sometimes forms a thin layer over the tonsils and the
posterior wall of the pharynx. In infants, a confervoid growth (lepto-
thrix buccalis) is occasionally seen upon the inflamed surface, and may
be mistaken, by a careless or inexperienced observer, for diphtheritic
exudation.* Late in the disease, a few superficial erosions may appear
in the epithelial layer, but this lesion is not constant.
In some cases, characterized by extensive serous infiltration into the
submucous connective tissue, the mucous membrane appears pale and
smooth, and is soft and sticky to the touch.
The uvula is often oedematous and so elongated that it lies upon the
base of the tongue or rests upon the posterior wall of the pharynx or
the laryngeal surface of the epiglottis. In some instances it is at-
tached by viscid mucus to one of the arches of the palate; in others,
the posterior palatine arches are also œdematous, and "appear like the
wings of a central portion, the body of the uvula, which no longer pre-
sents as a free and pendent structure.Ӡ
The cervical and submaxillary glands are generally swollen and
painful. When the inflammation is intense, it may involve the sub-
* Diseases of Children, by J. Lewis Smith, M.D., p. 660.
† Cohen's Diseases of the Throat and Nasal Passages, p. 85.
.
DISEASES OF THE ORGANS OF DIGESTION.
531
!
stance of the tonsils and the adjacent connective tissue. In a fatal
case reported by Rilliet and Barthez* these glands were enlarged, soft-
ened, and infiltrated with pus, and the pharyngeal surface was in-
tensely congested, thickened, and covered with a layer of bloody mucus.
Symptomatology. The local symptoms are frequently preceded
by slight fever, loss of appetite, and a feeling of lassitude and depres-
sion. At the commencement of the disease there is an abnormal dry-
ness of the mucous membrane, and a sensation of heat, soreness, and
stiffness in the pharynx; but the surface soon becomes moist, and at
a later stage the patient is constantly coughing and hawking in order
to clear his throat of the viscid secretion poured out by the inflamed
follicles. Deglutition is painful in all except the mildest cases. In
health, the contraction of the muscles of the anterior palatine arches.
closes the isthmus of the fauces, and prevents the return of food into
the mouth, while the muscles of the posterior arches at the same time.
close the opening into the nasal cavities. In severe forms of this dis-
ease these muscles become so extensively infiltrated with serum that
their contractile power is lost, and consequently food and drink are
ejected through the mouth and nose as soon as the patient attempts
to swallow. If the constrictors of the pharynx be also paralyzed by
serous infiltration, the bolus, after it passes the anterior palatine
arches, becomes impacted, and is expelled only by violent and long-
continued efforts, during which a portion of the ingesta frequently
enters the larynx and causes spasmodic cough. The patient soon.
becomes alarmed at these attacks and refuses all nourishment.† The
voice acquires a nasal tone, articulation is impaired, and speech is
difficult and often painful.
In ordinary catarrhal inflammation involving the upper part of the
pharynx, there is often transient deafness with noises in the ears. In
severe cases the morbid process may extend through the Eustachian
tube to the tympanum, and give rise to suppurative inflammation of
the middle ear, attended with excessive pain, which persists until the
pus escapes down the tube or bursts through the membrana tym-
pani, when the suffering at once subsides.
When the lower portion of the pharynx is attacked, the throat is
swollen externally, and the pain is increased by movements of the
larynx and by pressure at the sides of the neck.
Elongation of the uvula causes a constant desire to swallow, and in-
duces a hacking cough, which is aggravated whenever the patient as-
sumes a recumbent posture. In infants and young children the cough
is often hoarse or harsh and croupal. In the majority of cases there is
a mild grade of catarrhal stomatitis; the breath is slightly offensive,
the tongue is coated, and the salivary secretion is increased. When
* Maladies des Enfants, p. 233 et seq.
† Niemeyer's Text-book of Practical Medicine, vol. i., p. 447 et seq.
532
A SYSTEM OF MEDICINE.
the disease pursues a mild course, the systemic disturbance is trifling;
there is usually a moderate febrile action and a slight acceleration of
respiration and circulation. In severe cases the pulse often rises to
120 or even 140 beats in the minute, the temperature is correspond-
ingly elevated, and there may be severe headache, backache, and
pains in the extremities.
In young children, pain and difficulty in swallowing may be slight
or absent, but the constitutional symptoms are more pronounced than
in adults. In grave cases the invasion of the disease is sometimes
accompanied by high fever, vomiting, excessive restlessness or drowsi-
ness and stupor, muscular twitchings, delirium, and occasionally
clonic convulsions. Even in the mildest forms there is more or less
nervous irritability and insomnia. Thirst is usually intense, but the
appetite is diminished or lost.*
The duration of an attack is generally from three to ten days.
Diagnosis. When the inflammation is confined to one tonsil and
its immediate vicinity, acute catarrhal sore throat may be confounded
with quinsy, but is easily distinguished by the greater tumefaction of
the gland in the latter affection.
In children who are too young to describe their feelings, the diag-
nosis is often difficult. According to Meigs and Pepper,† "there are
no local symptoms in two-thirds of the cases at the invasion, nor in
some instances at any period of the attack." The violent constitutional
disturbances may, therefore, be ascribed to any cause except the right
one; and if inspection of the throat be neglected, the disease may be
mistaken for scarlatina, indigestion, or cerebral irritation due to denti-
tion. In some instances it may also be confounded with diphtheria,
on account of the confervoid growths upon the mucous membrane of
the pharynx, but the soft pultaceous character of this deposit, its easy
removal, and its microscopical appearance are so characteristic that an
error in diagnosis is hardly possible.‡
Prognosis. In idiopathic cases the tendency is almost invariably
to spontaneous recovery. A few instances have been recorded in
which extension of the inflammation to the larynx produced fatal
œdema of the glottis, but such a termination is exceedingly rare. In
debilitated and cachectic subjects there is often induced a permanent
weakness of the mucous membrane, which predisposes to subsequent
attacks. According to Gubler§ and Broadbent,|| this form of sc
throat is occasionally followed by paralysis of the soft palate.
sore
When this affection is associated with a grave constitutional malady,
although not dangerous per se, it may produce a fatal result by aggra-
vating the primary disease.
* Meigs and Pepper, Diseases of Children, p. 348.
† Loc. cit.
2 Archives Gén. de Méd., 1859-60.
Smith, loc. cit.
|| Lancet, 1871.
DISEASES OF THE ORGANS OF DIGESTION.
533
Treatment. The predisposition to sore throat can often be coun-
teracted to a great extent by inuring the skin to exposure by daily
cold baths, followed by brisk friction with a coarse towel or a flesh-
brush. Persons subject to this disease should wear flannel, silk, or
woollen underclothing, and avoid getting the feet wet or sitting in
damp garments. The remedies most frequently indicated are: Acon.,
Apis, Arum tri., Bapt., Bell., Canth., Capsic., Gelsem., Hepar, Ignat.,
Kali bich., Lach., Lycopod., Merc., Nux vom., Phytol., Pulsat., and Rhus
tox.
When food and drink are ejected through the nose, compare Bell.,
Lach., Lycopod., Merc., Nitric acid, and Phosphorus.
For elongation and œdema of the uvula, Raue* recommends Acon.,
Bell., Coff., Crot. tig., Lach., Merc., Natr. mur., and Phos.†
Special Indications.-Aconite.-High fever with burning, unquenchable
thirst, restlessness and great nervous excitability; fauces and pharynx dark red; burn-
ing or pricking pains, with a feeling of dryness and contraction in the throat; deglu-
tition difficult or painful; uvula elongated; the attacks occur during dry, cold weather;
sanguine or nervous temperament. This remedy is useful only in the early stages.
Apis. Bright-red oedematous swelling of tonsils, palate and uvula; throat swol-
len both internally and externally; difficult deglutition and respiration; burning,
stinging pains; accumulation of tenacious mucus in the throat; fever without thirst;
aggravation from heat, amelioration from cold.
Arum triph.-Lips and corners of the mouth cracked and bleeding; the throat
and tongue are so sore that the patient refuses both food and drink.
Baptisia.—Fauces dark red; tonsils swollen; can swallow nothing but liquids;
the throat feels contracted; abundant secretion of mucus which can neither be swal-
lowed nor expectorated; offensive breath; the tongue has a yellowish-brown streak
down the centre and red shining edges; absence of pain; great prostration.
Belladonna.-Fances and pharynx deep red; tonsils and palate swollen;
worse on the right side; violent and painful constriction of the throat, worse when
attempting to swallow fluids; sensation as if the parts were too narrow; constant in-
clination to swallow; dryness, scraping, burning, and stinging in the throat; uvula
elongated; throat swollen externally and painfully sensitive to touch; accumulation
of ropy mucus in the throat. Violent fever with intense thirst; hot, red, swollen
face; throbbing headache; dilated pupils, and pulsation of temporal and carotid
arteries.
Cantharides.-Throat feels on fire; constriction and intense pain at the back of
the throat; difficult deglutition.
Capsicum.—Dark redness of the throat, with a burning, pungent sensation in
the pharynx; fetid breath; burning and constriction worse between the acts of deglu-
tition; dry, teasing cough from elongation of the uvula.
Gelsemium.-Dryness and soreness of the throat; swallowing causes shooting
pains in the ears; chilliness in the back; languor and drowsiness; characteristic head-
ache.
Hepar.-Sensation as if a splinter or fish-bone were sticking in the throat;
stitches in the throat extending to the ears when swallowing; pressure in the throat as
from a plug; scrofulous patients.
Ignatia.—The pain and soreness are worse when not swallowing and when swal-
lowing liquids, and are relieved by swallowing solid food; stitches in the throat only
between the acts of deglutition; nervous patients.
Kali bichr.-Accumulation of stringy tenacious mucus in the pharynx; sharp
* Pathology and Therapeutics, p. 109.
† Compare also Apis, Capsic., and Rhus tox., and consult the treatment of chronic
catarrhal sore throat.
534
A SYSTEM OF MEDICINE.
shooting pains in the throat, extending into the ears; the inflammation aff ets princi-
pally the arches of the palate and the tonsils; morning aggravation.
Lachesis.-The throat is exceedingly sensitive to pressure; the soreness is worse
on the left side, or goes from left to right; the mucous membrane is swollen and pur-
plish; empty deglutition is more painful than swallowing food; liquids escape through
the nose on attempting to swallow; the distress is greater than the local symptoms
would seem to warrant; great dryness of the throat, worse after sleep.
Lycopodium.-The inflammation begins or is worse on the right side; choking
sensation, which induces constant swallowing; deglutition difficult; food and drink
are ejected through the nose; nose stuffed; cervical glands swollen; child very irri-
table on first waking; worse from 4 to 8 P.M. and from warm drinks.
Merc. sol.-Throat swollen and very red; raw smarting sensation in the throat;
feeling of a lump in the pharynx, with constant desire to swallow; inability to swallow
liquids they return through the nose; profuse salivation; fetid breath; tongue
swollen and flabby, taking the imprints of the teeth; gums swollen and tender; bad
taste in the mouth; uvula elongated; glands swollen, much perspiration which affords
no relief; all symptoms worse at night.
(When the inflammation is intense and there is great oedema of the throat, Merc.
corr. is preferable to Merc. sol. If the disease affect principally the right side, and the
tongue has a thick yellow coating at the base, Merc. jod. flav. should be given.)
Nux vom.-Throat feels rough, raw, and sore, as if scraped; constant hawking;
sensation of a plug or lump in the pharynx when swallowing; dry cough with head-
ache and pains in the hypochondria when coughing; soreness in the stomach and ab-
dominal walls; cross and irritable; morning aggravation.
Phytolacca.-Sensation as if a red-hot ball had been lodged in throat; swelling
of the tonsils and soft palate; sensation as if the trachea were compressed; the throat
feels enlarged; constant hawking; great prostration; fetid breath; violent pains in
the back and limbs.
Pulsatilla.-Bluish redness of the pharynx, tonsils, and uvula, with swelling of
the affected parts; sensation of a lump in the throat; dryness and soreness of the
throat; chilliness toward evening with increase of the soreness; burning fever with-
out thirst; always worse in a warm room and better in the open air.
Rhus tox.-Fauces and pharynx edematous; the curtain of the palate puffed
and pink; uvula elongated, puffed translucent, the end nearly spherical, looking like
a great drop of fluid or jelly just ready to fall off; vesicles in the pharynx and on the
palate and uvula; intolerable roughness of the pharynx and larynx; great debility.*
Compare also Amygdala persica, Baryta c., Cham., Dulc., Sulph., etc.
Elongation and oedema of the uvula, when intractable to internal
medication, may be quickly relieved by a few punctures which allow
the effused serum to escape, or by excision of the tip with scissors or
the uvalatome.
In all except the mildest cases the patient should be confined to the
bed or lounge, and restricted to a light and easily digestible diet. The
local distress may be palliated by the external application of warm,
moist compresses, by the free use of demulcent drinks, and by allow-
ing small pieces of ice to slowly melt in the mouth or, when cold
aggravates, by gargles of very hot water. Intense burning heat of the
skin may be relieved by frequently sponging the surface with tepid
water, to which a small quantity of alcohol has been added. The
patient should remain in the house until the throat has regained its
normal condition, for a careless exposure during the first few days of
convalescence is often followed by a relapse, which sometimes exceeds
in severity the original attack.
* Dunham's Lectures on Mat. Med., vol. i., p. 154.
DISEASES OF THE ORGANS OF DIGESTION.
535
CHRONIC CATARRHAL SORE THROAT.
Synonyms. Chronic catarrh of the fauces, Chronic pharyngeal
catarrh, Chronic catarrhal angina, Relaxed sore throat, etc.
Chronic catarrhal sore throat is characterized by congestion and re-
laxation of the mucous membrane of the pharynx, palate and uvula;
there is no marked involvement of the follicles, and the morbid pro-
cess never terminates in ulceration.
Ætiology. This disease is usually the result of repeated attacks
of acute catarrhal sore throat, but may also be due to disorders of the
alimentary tract and, in women, to uterine irritation. It is frequently
observed in persons who are addicted to the excessive use of alcoholic
stimulants and tobacco or indulge too freely in the pleasures of the
table. It is most prevalent in damp, variable climates and, accord-
ing to Cohen,* may exist with any diathesis. Acute exacerbations
may be provoked by exposure to the night air, by prolonged stay in
overheated rooms, and in some instances merely by fatigue.†
Anatomical Characters.-The faucial mucous membrane is
swollen, congested, and relaxed, presents a doughy or pasty appear-
ance, and is often thrown into prominent ridges or folds by infiltration
of the submucous connective tissue. In some instances the surface is
coated with a transparent film of mucus. The superficial veins of the
palatine arches, and occasionally those of the pharynx, are engorged,
tortuous, and varicose. A few enlarged follicles are observed in some
instances, and the papillæ at the base of the tongue are frequently
congested and hypertrophied. The soft palate is relaxed and depend-
ent. The uvula is increased in length and, occasionally, in breadth.
Its muscular structure is seldom implicated, but the enveloping mucous
membrane is often so elongated that it lies upon the base of the tongue,
and is sometimes drawn into the larynx during inspiration, or into the
œsophagus during the act of deglutition. This membrane usually
tapers to a fine point, but sometimes forms, at the extremity of the
uvula, a spherical swelling resembling an opaline vesicle, from which
watery mucus constantly drips. In advanced cases the morbid pro-
cess may extend to the vault of the pharynx and the posterior nares.
Symptomatology. On waking in the morning the throat feels.
dry and stiff; there is a sensation as if a foreign body had lodged in
the pharynx, and considerable hawking is required to cleanse the
parts of the mucus which has accumulated overnight; during the
day the secretions are generally swallowed with the saliva, and con-
sequently there is little or no expectoration. In some cases the local
discomfort is most marked in the evening, and not unfrequently it
rouses the patient from sleep; it is temporarily relieved by either hot
or cold drinks and by insalivation. When the uvula is much elon-
* Op. cit., p. 178.
† Mackenzie: Pharynx, Larynx, and Trachea, p. 39.
536
A SYSTEM OF MEDICINE.
gated it causes a tickling, spasmodic cough, and may induce nausea
and vomiting; during sleep it is occasionally drawn into the larynx,
as already mentioned, and the patient suddenly awakes with a suffo-
cative attack. In some cases, however, considerable elongation of the
uvula may exist without producing any symptoms.
There is often a bad taste in the mouth; the bowels are inclined to
be constipated, and there is more or less languor and depression; but
the general health is never seriously affected.
Diagnosis. This rests upon the anatomical appearances and the
symptoms above described.
Prognosis. The prognosis is always favorable. The disease rarely
terminates in spontaneous recovery, but may exist for years without
causing structural changes or producing any serious inconvenience.
Treatment. The use of tobacco and spirituous liquors must be
strictly forbidden, and the patient must avoid late hours, overheated
rooms, and exposure to the night air. The remedies which, in the
writer's experience, have proved most efficient in this disease are:
Alumina, Hyos., Kali bich., Lach., and Nux vom. China, Capsic., Cof-
fea, Hepar, Ignat., Iod., Kali c., Lycop., Merc., Nitric acid, Phos., Puls.,
Silic., and Sulph. may also be required in some cases. Where elonga-
tion of the uvula refuses to yield to medicine, the mucous membrane
at the extremity of that organ must be excised. This simple opera-
tion at once relieves the tickling cough, but frequently increases the
local discomfort, and may give rise to severe odynphagia. The exacer-
bation is only temporary, however, and is followed in a few days by a
marked remission of all the symptoms.
Therapeutic Indications. -Alumina.--Great dryness of the throat, especially
on awaking, with hawking and sensation of a lump in the throat; mucous membrane
and blood vessels relaxed; uvula elongated and dark red.
Capsicum.-Dry, hacking cough, caused by elongation of the uvula; fetid
breath; burning sensation in the throat.
Coffea.-Uvula elongated, and swollen; sensation of a plug in the throat, with
constant desire to swallow; soreness of the throat aggravated by cool air.
Hyoscyamus.-Dry, hacking, or spasmodic cough, worse when lying, relieved
by sitting up; uvula elongated and palate relaxed.
Iodine.—Uvula swollen and elongated; scraping and burning sensation in the
throat, extending into the oesophagus.
Kali bich.- Uvula relaxed, with sensation of a plug in the throat, not relieved
by swallowing; viscid, stringy expectoration; morning aggravation.
Lachesis.-Uvula elongated; throat so dry that the patient awakes choking;
external throat sensitive to pressure; aggravation after sleeping.
Merc. sol.-Uvula swollen and elongated; salivation, fetid breath, and flabby
tongue.
Nux vom.-Dryness and smarting in the throat; uvula elongated; constant
hawking and hemming to clear the throat in the morning; cough hurts the abdominal
walls; characteristic mental and gastric symptoms.
Phosphorus.-Uvula elongated, with burning and dryness in the throat; the
mucus is detached with difficulty.
Pulsatilla.-Uvula elongated and flabby; varicose veins in the throat; dryness
of the mouth without thirst; chilliness; cannot bear a warm room; characteristic
mental symptoms.
DISEASES OF THE ORGANS OF DIGESTION.
537
Sulphur.-Great dryness and burning in the throat, first right side and then left,
with elongation of the uvula.
Compare, also, the treatment of Acute Catarrhal Sore Throat and
Chronic Follicular Sore Throat.
CHRONIC FOLLICULAR SORE THROAT.
Synonyms.-Chronic pharyngitis, Follicular pharyngitis, Chro-
nic glandulous pharyngitis, Chronic laryngo-pharyngitis, Granular
pharynx, Granular sore throat, Clergyman's sore throat; Angina im-
petigenosa, Angina glandulosa, Dysphonia clericorum, etc.
This disease is essentially a chronic catarrhal lymphadenitis of the
pharynx, resulting in hypertrophy of the follicles and thickening of
the mucous and submucous tissues. In advanced cases, the follicular
glands of the nasal fossæ, palate, base of the tongue, epiglottis, and
larynx are also involved.
Etiology.-Chronic follicular sore throat attacks men more fre-
quently than women, and prevails more extensively in cities than in
rural districts. It generally occurs during the vigorous period of ado-
lescence, from twenty-five to forty years of age-but is also occasion-
ally seen in children. According to Professor Horace Green,* it is
often hereditary. Persons who are anæmic, or debilitated by mental
overwork, sedentary habits and lack of exercise, are especially liable
to contract follicular disease of the pharynx. The strumous, rheu-
matic, and tuberculous diatheses may also be regarded as predisposing
causes. In some instances this form of sore throat may occur as the
sequel of repeated attacks of acute or subacute catarrhal pharyngitis,
while in others it may be dependent upon gastric or intestinal irrita-
tion. The most frequent exciting causes are: (1) Overexertion of
the voice, (2) exposure to cold, and (3) irritation of the weakened
mucous membrane by "mechanical and chemical emanations from
various manufacturing processes."‡
There is a wide-spread belief among the laity that this affection is
confined almost exclusively to the clergy, but a careful analysis of
Professor Green's§ four hundred cases shows that less than twenty per
cent. of the patients were members of that professsion, or could in
any way be classed as public speakers. It is also probable, as Cohen||
suggests, that the prevalence of this disease among clergymen is
largely due to the inequalities of temperature to which they are often
exposed while preaching.
Anatomical Characters.-The appearance of the throat is very
characteristic. In the early stages the mucous membrane is more or
less deeply congested, while the enlarged and hypertrophied follicles
* Treatise on Diseases of the Air-passages, etc., p. 159.
† Cohen, op. cit., p. 181.
? Op. cit.
Cohen, loc. cit.
|| Loc. cit.
538
A SYSTEM OF MEDICINE.
may be seen projecting from its surface and forming hemispherical,
elliptical, or irregularly shaped elevations that are usually about the
size of millet-seeds, but, in exceptional cases, may attain the bulk of
a small pea. These prominences occur singly or in groups, are usually
of a deeper red than the surrounding tissues, and may be either trans-
parent or opaque. Each elevation is surrounded at its base by a nar-
row zone of inflammation that appears like a fine red line. The in-
flamed mucous membrane is often dry and glistening, the orifices of
the follicles are bright red, and a turbid viscid mucus adheres to the
affected parts in clumps or strands. In some instances the normal
transparent exudation collects upon the healthy portion of the mem-
brane in minute drops, which might easily be mistaken for herpetic
vesicles. The surrounding parts look sunken by contrast, and the
throat, in these cases, often presents a deceptive appearance of rawness;
but if the supposed vesicles be carefully wiped off, the underlying
mucous membrane will be found to have suffered no loss of epithelium.*
The follicular glands of the soft palate, the uvula, and the base of the
tongue may be involved in the morbid process; but the tonsils are
not usually affected nor the uvula elongated at this stage of the disease.
The mucous membrane of the larynx is hyperæmic after protracted
use of the voice, but regains its normal condition after a few days' rest.
As the malady progresses, the follicles undergo further hypertrophy,
and ultimately coalesce and form "broad flattened elevations or long
ridges," which often have a velvety surface, and are elastic to the
touch. These extend in various directions over the mucous membrane,
and are usually surrounded by a network of injected superficial veins.
The diseased follicles now pour out a viscid secretion, which either
hangs like a thread from the point of exit, or adheres to the part in
small white patches. In some instances this exudation has a cheesy
character; in others it resembles the contents of an acne pustule;
and occasionally it is "chalky in appearance and calcareous in com-
position." When the glandular tissue at the vault of the pharynx
is involved, greenish-yellow masses of hardened mucus may be seen
adhering to the posterior wall of the pharynx behind the soft palate;
and when the disease has extended to the posterior nares or the pos-
terior surface of the palate, strings of tenacious mucus will hang from
the velum into the pharynx. The mucous membrane of the posterior
pharyngeal wall is often excoriated by the acrid discharges that flow
over it, and is frequently atrophied, whitish, and semi-transparent.
The tonsils are enlarged, the soft palate is relaxed, the uvula is elon-
gated, and there is a chronic inflammation of the mucous membrane
of the larynx. Real vesicles may sometimes be seen upon the palate
and uvula. § The inflamed follicles may now suppurate or undergo
* Cohen, loc. cit.
‡ Ibid.
+ Mackenzie, op. cit., p. 48.
? Cohen, loc. cit.
DISEASES OF THE ORGANS OF DIGESTION.
539
superficial ulceration; and small ulcers, covered with a grayish or
whitish exudation, may also form in the epithelial layer of the mucous
membrane of the pharynx, tonsils, soft palate, and uvula. In severe
cases, the discharge from the ulcers becomes purulent or sanguinolent;
and a few instances have been reported in which alarming, and even
fatal, hæmorrhage was caused by erosion and perforation of the pala-
tine and carotid arteries. As a rule, however, extensive ulceration
occurs only in scrofulous subjects, or when the follicular disease is
associated with syphilis or phthisis. †
Symptomatology.-The symptoms vary greatly in different in-
dividuals and at different stages. In some cases they steadily increase
in severity; in others they are aggravated whenever the patient takes
cold or strains the vocal organs, and after a few days or a few weeks
partially subside, and then remain stationary until another imprudent
act provokes a fresh exacerbation. The affection begins so insidiously
and causes so little annoyance at the outset, that a physician is seldom
consulted until it has existed for months or years. In fact, a consid-
erable hypertrophy of the follicles may occur, and the patient not be
aware that his throat is at all affected. At first there is merely a sen-
sation of dryness and stiffness in the pharynx, associated, in some
instances, with a tickling cough that is either dry or attended with a
scanty expectoration of viscid mucus. When the cough occurs in
severe paroxysms, it causes a feeling of soreness and tenderness in the
larynx and about the arch of the palate. As the malady progresses,
the throat becomes excessively dry and sore; there is a sensation of
heat and pricking in the pharynx; and a feeling of obstruction in the
larynx causes frequent hawking. In persons whose occupations re-
quire a constant use of the voice, one of the most important symp-
toms is the marked impairment of the vocal powers. This may occur
early in the disease from "a mere extension of the nervous influence
of the pneumogastric nerve,"‡ or ensue at a later stage from implica-
tion of the larynx. The voice is muffled, hoarse, or feeble, and articu-
lation is difficult and often painful. Sometimes the hoarseness is tem-
porarily relieved by drinking water. At other times, if the patient
persist in the effort to talk, he becomes aphonic for the remainder of
the day. A "change of key" frequently occurs in the middle of a
sentence. In some cases the voice is deep and gruff in the morning,
but gradually rises in pitch, and becomes high and shrill in the even-
ing; in others, the patient wakes with dysphonia or complete aphonia,
but the voice steadily improves with exercise, and by noon is nearly
natural, with the exception of a slight hoarseness. In persons who
limit the use of the vocal organs to the requirements of ordinary con-
versation, these symptoms do not occur until late in the disease, and
then only as the result of a distinct laryngeal complication.
* Cohen, loc. cit.
† Mackenzie, loc. cit.
Cohen, loc. cit.
540
A SYSTEM OF MEDICINE.
When the orifices of the Eustachian tubes are involved, the hearing
becomes affected, and in some cases the deafness is permanent. When
the morbid process extends to the nasal fossæ and the mucous mem-
brane of the palate, the senses of smell and taste are impaired or lost.
In some cases there is nervous dyspnoea; in others, the respiration is
obstructed by tumefaction and thickening of the nasal mucous mem-
brane, or by the accumulation of mucus in the nasal cavities.
Deglutition is often difficult and painful. In some instances the
patient is obliged to subsist entirely upon a liquid diet, but occasion-
ally solids are swallowed more readily than fluids. In the worst cases
there may be complete aphagia, but this is rare. The dysphagia may
be purely nervous, or it may be due to ulceration or to loss of contrac-
tile power in the deglutory muscles from infiltration or atrophy of the
muscular tissues.
When the disease is fully developed, the cough is sometimes severe,
and in rare instances may be accompanied by hectic fever, rapid pulse
and progressive emaciation. It may be induced by the presence of
irritating secretions in the pharynx, by elongation of the uvula, and
by extension of the inflammatory process to the larynx. More fre-
quently, however, cough is absent; but the patient, in his efforts to
clear the throat, is almost constantly giving utterance to "a kind of
high-pitched grunt or a hem."* The expectoration may be mucous.
or muco-purulent, thin or viscid, and is occasionally blood-streaked;
not unfrequently it contains small pellets of mucous or bloody semi-
solid masses, which have been drawn down from the retro-nasal por-
tion of the pharynx, the posterior nares, or the vault of the pharynx.
The constitutional disturbance is usually very slight. The patients.
are often excessively nervous, and can hardly be convinced that they
are not the victims of phthisis; † there may be languor and debility,
headache, coolness of the extremities, palpitation of the heart, evidences
of dyspepsia, and, in some instances, as already mentioned, hectic.
fever and emaciation: but in the great majority of cases the general
health is not materially impaired.
Diagnosis. An ordinary case of chronic follicular sore throat is
not likely to be mistaken for any other malady. In those exceptional
instances in which the symptoms simulate those of phthisis, the diag-
nosis is readily established by inspection of the pharynx and exami-
nation of the lungs by auscultation and percussion. It must not be
forgotten, however, that the two affections sometimes coexist.
Prognosis. Under appropriate treatment a complete cure of the
pharyngeal trouble may be confidently expected in the great majority
of cases; but in regard to the perfect restoration of the vocal powers
the prognosis is less favorable, especially if the disease has existed
* Cohen, loc. cit.
† Niemeyer, op. cit., vol. i., p. 449.
↑ Mackenzie, op. cit., p. 51.
DISEASES OF THE ORGANS OF DIGESTION.
541
several years. In the case of clergymen, teachers, singers, etc., the
voice is sometimes permanently weakened to such an extent that the
patients are obliged to relinquish their professional work and seek
occupations requiring less vocal effort.
Treatment.-As Cohen* pertinently remarks, both the disease and
the treatment are "eminently chronic." The general hygienic man-
agement is the same as in acute catarrhal sore throat. In all cases the
protracted use of the voice must be interdicted until the curative pro-
cess is well advanced; and where there is a distinct and severe laryn-
geal complication, absolute rest of the vocal organs, for a few days or
a few weeks, is imperatively demanded.
The remedies most frequently indicated are: Alumina, Argent. met.,
Argent. nitr., Arnica, Arum tri., Kali bich., Lachesis, Lycopod., Merc. iod.
flav., Merc. iod. rub., Natrum mur., Nux vom., Phosphorus, Phytolacca,
Plumbum, and Rhus tor. Esculus, Chimaph., Hydrastis, Natrum
arsen., and Petrol. may also occasionally prove serviceable.
Special Indications.-Alumina.-Voice husky, hoarse, or weak, especially in
the morning on waking; rawness and soreness in the throat, with a sensation as if a
splinter were sticking in the pharynx; the mucous membrane is dark red, has a glazed
look, and is very dry, or there may be an accumulation of thick. tough mucus; uvula
elongated and dark red; amelioration from warm food and drink.
Argent. met.-Hoarseness, with copious accumulation of mucus, when begin-
ning to sing or talk; easy expectoration of mucus, which looks like boiled starch.
Argent. nitr.-Loss of voice; difficult detachment of thick, tenacious mucus;
constant hawking and occasional gagging; feeling of a pointed body in the throat
when swallowing, breathing, or moving the neck.
Arnica.-Great hoarseness, with pain in the fauces and larynx after protracted
use of the voice; stinging in the back of the throat between the acts of deglutition.
Arum tri.-Voice hoarse, uncertain, constantly changing; hoarseness is aggra-
vated by talking; accumulation of mucus, which causes constant hawking.
Kali bich.-Posterior wall of pharynx dark red and often glossy, cracked and
bleeding; accumulation of tenacious stringy mucus in the throat and posterior nares;
yellowish or greenish masses of hardened mucus are hawked up in the morning (Lyc.).
Lachesis.-Painful deglutition, with constant desire to swallow; spasmodic con-
traction of the fauces; hawking of mucus, with rawness and dryness of the throat;
hoarseness; rawness and scraping in the larynx; external throat very sensitive to
touch; solids swallowed more readily than fluids; worse on left side and worse after
sleeping.
Lycopodium.-Brownish-red appearance of the fauces; worse on the right
side; hoarseness: hardened masses of greenish-yellow mucus are hawked up in the
morning (Kali bich.).
Merc. iod. flav.-Base of tongue covered with a thick dirty-yellow coating;
much tenacious mucus in the throat; hawking causes gagging; hoarseness and apho-
nia;
fetid breath; salivation; worse on the right side.
Merc. fod. rub.-Voice hoarse and husky, or complete aphonia; uvula elon-
gated; hawking of tough white mucus, or hard greenish lumps; ptyalism; fetid
breath; the throat is worse on the left side.
Natrum mur.-There is a feeling of great dryness in the throat, and yet the
patient is constantly hawking up thin transparent mucus; hoarseness, with accumula-
tion of mucus in the larynx; especially indicated after the topical application of
Argentum nitr.
Nux vom.-Dryness, smarting, and burning in the pharynx; voice hoarse; has
* Loc. cit.
542
A SYSTEM OF MEDICINE.
to clear the throat constantly, especially in the morning; dull frontal headache and
the characteristic gastric symptoms.
Phosphorus.—The throat is so dry that it fairly glistens; roughness, scraping,
and burning in the pharynx; hoarseness and roughness of the voice; aphonia from
prolonged loud talking.
Phytolacca.-Dryness of the throat, with sensation of scraping and rawness;
constant hacking to rid the throat and posterior nares of mucus; feeling when swal-
lowing as if a ball of red-hot iron had lodged in the pharynx; choking sensation;
cannot drink hot fluids.
Plumbum.-The disease goes from right to left; tough mucus in the throat and
posterior nares; tonsils inflamed and covered with small abscesses; sensation of a plug
in the throat; spasmodic contraction of the fauces.
Rhus tox.—Hoarseness from overstraining the voice; the hoarseness is improved
by talking; the throat feels sore and stiff; roughness and soreness in the larynx.
Compare also the treatment of acute and chronic catarrhal sore
throat, and the chapters on Chronic Nasal Catarrh and Chronic Catar-
rhal Laryngitis.
When the local suffering is severe, it may be palliated by demulcent
drinks; but astringent gargles are not required. The prevalent method
of treating this disease by the topical application of caustics, etc.,
cannot be too strongly condemned.
ULCERATED SORE THROAT.
Ulceration of the mucous membrane of the throat is usually the re-
sult of catarrhal inflammation, syphilis, or tuberculosis. Occasionally
it occurs in debilitated persons from exposure to septic influences. In
cases of malignant scarlatina and diphtheria, the attendants, when ex-
hausted by protracted watching and loss of rest, frequently contract
this form of sore throat, and it is also common in medical students
who spend much time in the dissecting-room or in the wards of a
hospital.*
Ulceration of the mucous follicles is regarded by some authors as a
manifestation of scrofulosis; but it is probable that in the severe
grades of this so-called scrofulous ulceration the morbid process is due
to a syphilitic taint, either hereditary or acquired, and that, in the
milder cases, the strumous diathesis simply aggravates an existing
catarrhal inflammation.
Anatomical Characters.-The appearance of catarrhal ulcers
has already been described.† In some instances they are confined to
the extreme upper or lower portion of the pharynx, and in these cases,
if rhinoscopic or laryngoscopic examination be neglected, the true na-
ture of the disease generally escapes detection.
Two varieties of syphilitic ulceration may be recognized-the super-
ficial and the deep. The superficial ulcers attack by preference the
soft palate, but may also be found on the tonsils and the pillars of the
fauces. They have irregular, ragged, undermined edges; their bases
+ Vide preceding chapters.
* Mackenzie, op. cit., p. 42.
DISEASES OF THE ORGANS OF DIGESTION.
543
are covered with an ichorous pus or with whitish or yellowish tenacious
lymph; and the surrounding parts are inflamed, but never indurated.
The deep or perforating ulcers, which are almost invariably produced
by the softening of gummata, have steep, crested edges, lardaceous
bases, and hard, inflamed, copper-colored borders; they may occur in
any part of the throat. The ulceration often extends to the nasal pas-
sages and to the larynx. It may destroy the uvula and portions of
the soft palate, and penetrate deeply into surrounding structures. In
some instances it causes perforation of the cervical blood vessels and
fatal hæmorrhage; in others it produces caries of the base of the skull
or of the cervical vertebræ, and not unfrequently it provokes fatal
lesions of the brain and spinal cord.*
Tubercular ulcers are lentil-shaped, and have "a caseous, broken-
down floor, with undermined, hyperæmic edges, in which new tuber-
culous deposits are imbedded in various stages of development. These
rapidly disintegrate, and cause necrosis of the mucous membrane
lying between them." In the immediate vicinity of these ulcers may
be seen small grayish or yellowish nodules which ultimately become
the seat of fresh ulceration. The morbid process begins upon the lat-
eral walls of the pharynx, and gradually extends to the posterior wall,
the soft palate, and the roof of the mouth. In the majority of instances
it also spreads to the epiglottis and the larynx.‡
Ulcers, due to slight septicemia, are always superficial, present a
whitish appearance, are round or oval, and never coalesce. They are
usually found on the tonsils and fauces.§
Symptomatology.—In all cases of ulcerated sore throat there is
more or less inflammatory swelling of the affected parts with fetid
breath and ptyalism. The pain and difficulty in swallowing vary
according to the site of the ulceration, being most severe where the
tonsils and epiglottis are implicated.
In the syphilitic form of this disease the voice often loses its natural
resonance, and acquires a peculiar clang from tumefaction of the uvula
and perforation of the soft palate; the breath is horribly offensive;
and the local lesion is associated with external evidences of syphilis.
In the tubercular variety the soreness of the throat is marked and
persistent; deglutition is excessively painful, and is often attended
with violent stabbing pains in the ears; and aphagia is not uncom-
The lungs, if not primarily implicated, soon become involved;
the well-known phenomena of acute pulmonary tuberculosis super-
vene; and death ultimately ensues from exhaustion.
mon.
In both the syphilitic and tubercular forms of this affection, hoarse-
* For a detailed description of syphilitic ulceration of the throat, the reader is re-
ferred to Professor W. B. Trites's article on syphilis.
† O. Weber, quoted to Mackenzie, op. cit., p. 109.
Vide chapter on Tuberculosis.
? Mackenzie, loc. cit.
544
A SYSTEM OF MEDICINE.
ness and cough may be induced by the extension of the morbid pro-
cess to the larynx.
When the ulceration is due to slight septicemia, there is moderate
febrile disturbance, with splitting headache, shooting pains in the
limbs, drowsiness with inability to sleep, and a feeling of lassitude and
general malaise.*
Diagnosis. The diagnosis is based upon the history of the case,
the symptoms above enumerated, and especially upon the evidences
afforded by inspection of the throat.
Prognosis. The prognosis is favorable when the disease is due to
catarrhal inflammation or slight septicemia. In the syphilitic variety,
as long as the ulceration is superficial, there is but little danger to
life, unless the patient is seriously debilitated; but, if the ulcerative
process penetrate deeply, death may occur, as already mentioned,
from erosion and perforation of the cervical blood vessels, or from le-
sions of the brain and spinal cord. Even if these perils be avoided,
the extensive sloughing is often followed by vicious cicatricial contrac-
tions and by adhesions of the soft palate to the posterior wall of the
pharynx, producing permanent deformities which seriously interfere
with nasal respiration, speech, and deglutition.
Tubercular ulceration usually proves fatal within six months.
Treatment.-Topical applications are unnecessary. In some in-
stances they afford temporary relief, but as curative agents they are
far inferior to the properly selected remedy. The diet should consist
principally of nutritious liquids given by the mouth, or, in cases of
aphagia, by the rectum.
Therapeutic Indications.-Alumina.-Spongy ulcers secreting a yellowish-
brown, offensive pus; boring pain from the fauces to the right temple and head; the
throat is very dry or filled with thick, tough mucus.
Apis.-Deep ulcers, with oedematous or erysipelatous borders; burning, stinging
pains.
Argent. nit.-Ulceration, with a sensation as if a splinter were sticking in the
throat (Alum., Hep., Nitric ac.); uvula and fauces dark red; accumulation of tough,
tenacious mucus.
Arsenic.-The ulceration spreads superficially and threatens to become gan-
grenous; intense burning pain; great prostration; characteristic thirst and mental
symptoms.
Arum tri.-Putrid ulcers in the mouth and throat; fetid breath; salivation ;
lips and corners of the mouth raw, cracked, and bleeding; the patient refuses food and
drink on account of the soreness of the mouth and throat.
Aurum.-Putrid smell from the mouth like old cheese; deep ulcers affecting the
bones; mercurio-syphilitic cases.
Baptisia.-Painless, putrid dark ulcers; can swallow only liquids; fetid breath ;
great prostration; the tongue has a yellowish-brown streak down the centre, and red
tip and edges.
Capsicum.-Small, flat, burning ulcers in the mouth and fauces; pungent
- burning in the throat, relieved by swallowing.
Hydrastis.-Ulcers in the fauces and nasal passages; hawking of much tena-
cious mucus; bloody or purulent discharge from the nose; tongue flabby, taking the
* Mackenzie, loc. cit.
DISEASES OF THE ORGANS OF DIGESTION.
545
imprints of the teeth (Merc.); mercurial salivation; aggravation from the least expo-
sure to cold.
Ignatia.-Small, flat ulcers on the tonsils; the throat is most painful between
the acts of deglutition, and the soreness is temporarily relieved by swallowing.
Iodine.-Ulceration of the throat, with swelling of the cervical glands; scraping
and burning in the throat, extending to the oesophagus; elongation and swelling of
the uvula.
Kali bich.—The ulcers look as if they had been made with a punch, have ash-
colored bases and copper-colored borders; fauces and pharynx bright red or livid;
ulceration of the septum of the nose, with fetid discharge; viscid, stringy expectora-
tion.
Kali byd.-Ulceration and sloughing, with lancinating pains in the throat,
which is swollen internally and externally; thin, watery, excoriating discharge from
the nose, with or without destruction of the nasal tissues; weak, debilitated, scrofulous
subjects; mercurio-syphilitic cases.
Lachesis.-The throat is swollen, purplish, and ulcerated; the ulceration be-
gins or is worse upon the left side; spasmodic contraction of the fauces during deglu-
tition; can swallow solids more easily than liquids; intolerance of pressure about the
neck and throat; aggravation after sleeping.
Lycopodium.-Tonsils studded with small ulcers; fauces brownish-red; the
ulceration is worse upon the right side or goes from right to left. Aggravation from
4 to 8 P.M.
Merc. sol.-Suppurating, slowly spreading ulcers in the throat; ptyalism, fetid
breath and flabby tongue; pains worse at night; much perspiration, which affords no
relief; syphilitic cases.
Nitric acid.-The ulcers are irregular in outline, covered with pale, flabby
granulations, and bleed easily and profusely; pricking pains in the throat when swal-
lowing; great debility, sweating, and exhaustion; mercurio-syphilitic cases.
Sanguinaria.-Ulceration of the throat, with sensation of dryness, not relieved
by drinking; rush of blood to the head; circumscribed redness of the cheeks; char-
acteristic headache.
Compare also Belladonna, Carbo veg., Cinnabar, Hepar, Mercurius.
corr., Mercurius cyan., Muriatic acid, Nux v., Phosphoric acid, Phy-
tolacca, and Psorinum.
MEMBRANOUS SORE THROAT.
Synonyms. Non-malignant membranous sore throat, Herpetic
sore throat, Aphthous sore throat, "Cankered sore throat," (so-called)
Diphtheritic sore throat, False diphtheria; Angina herpetiformis,
Herpes pharyngis, Herpes gutturalis, etc.
Membranous sore throat is analogous to herpes of the skin, and is
characterized by the formation of vesicles, which, in the majority of
cases, are ultimately replaced by a fibrinous deposit similar in
anatomical structure and general appearance to the exudation of
diphtheria.
Etiology. According to Mackenzie,* this affection is extremely
rare in England. In this country, however, it is probably the most
frequent variety of sore throat. It occurs at all seasons of the year,
but prevails most extensively during the inclement, changeable
weather of autumn and early spring. It is not confined to any
locality nor to any particular class of society. Children are usually
* Op. cit., p. 57.
VOL. I.—35
546
A SYSTEM OF MEDICINE.
more susceptible than adults, but the disease may occur at any period
of life. Debilitated subjects sometimes contract it during the preva-
lence of diphtheria, and in these cases it is sometimes followed by
that malady. In many instances one attack seems to engender a pre-
disposition to another, and I have known patients in whom this affec-
tion recurred regularly every spring, for several years in succession.
Imperfect drainage and impure air are potential predisposing causes,
while the immediate exciting cause is usually exposure to cold when
overheated. Membranous sore throat may also accompany advanced
cases of syphilis and phthisis.
Anatomical Characters.-The disease usually begins on one
side of the throat and ultimately extends to the other. Occasionally
the morbid process is confined to the side first attacked, and more
rarely both sides are simultaneously affected. The parts usually
involved are the tonsils, the pillars of the fauces, and the soft palate;
the posterior wall of the pharynx and the hard palate are seldom
implicated. The cervical and submaxillary glands of the affected.
side are slightly swollen and tender. In the early stages of this
malady the mucous membrane is tumefied, reddened, and covered
to a greater or less extent with a fine vesicular eruption. The vesi-
cles are whitish or opaline, and are about the size of millet-seeds,
or, in some instances, slightly larger. They may occur singly or in
groups, and in the worst cases are so thickly clustered that the erup-
tion is practically confluent. Each vesicle is surrounded by an
inflammatory zone, and frequently has a dark spot at its apex. The
duration of this stage is from twenty-four to forty-eight hours. Occa-
sionally the vesicles are reabsorbed and the mucous membrane
rapidly regains its normal condition; but in the great majority of
cases the vesicles burst, and leave small, superficial, circular ulcers.
According to Mackenzie,* resolution may now take place, but my own
experience leads me to believe that such a termination is extremely
rare. Almost invariably each ulcer becomes covered, in a few hours,
with a white or yellowish-white fibrinous deposit that gradually
extends over the surrounding mucous membrane, coalesces with adja-
cent deposits, and forms patches which often attain considerable size.
In the course of a few days the ulceration heals, the exudation
becomes loosened, and is either expectorated or swallowed, and in a
very short time the last vestige of the disease is effaced. Simultane-
ously with the deposit in the throat a similar exudation may appear
upon other abraded mucous surfaces, and even upon cutaneous
ulcers. An herpetic eruption upon the inside of the lips and cheeks,
at the corners of the mouth, or upon the face, occasionally accompa-
nies the pharyngeal lesion. This symptom has a peculiar diagnostic
value, since medical aid is rarely summoned until the exudative
* Loc. cit.
DISEASES OF THE ORGANS OF DIGESTION.
547
stage is reached, and the eruption thus furnishes the only evidence
by which the vesicular nature of the disease can be positively demon-
strated. Unfortunately, however, it is absent in the majority of cases.
Symptomatology.-An attack of membranous sore throat is often
preceded for a few hours, or in some cases for two or three days, by
loss of appetite and a feeling of lassitude and general malaise. The
invasion of the disease is announced by a chill, or merely a sensation
of general coldness, followed by marked febrile reaction, the bodily
temperature often rising to 103°, or even higher, while the pulse varies
in frequency from 100 to 140 beats in the minute. The fever is
accompanied by a violent supra-orbital or frontal headache and pains
in the back and lower extremities. Deglutition is always more or less
painful, and is often attended with stitches in the ears. There is a
constant feeling of soreness, heat, and dryness in the throat, and this
sensation may extend to the posterior nares, and occasionally to the
larynx. The tongue is coated, the breath is offensive, and the com-
plexion is often sallow. In some cases there is profuse salivation; in
others there is an accumulation of ropy, tenacious, turbid mucus.
The uvula is frequently elongated and oedematous. When the orifices
of the Eustachian tubes are involved, there is transient deafness; and
extension of the morbid process to the larynx may give rise to hoarse-
ness, cough, and dyspnoea, and, in rare instances, to mechanical
asphyxia. In nearly all cases there is, throughout the whole course
of the disease, a degree of prostration entirely disproportionate to the
gravity of the local lesion. Under proper treatment the severe symp-
toms usually subside within forty-eight hours; and the duration of an
attack is rarely longer than a week or ten days, even in the worst
cases. In scrofulous and tuberculous subjects, however, the disease
sometimes shows a peculiar persistency, either recurring at frequent
intervals, or continuing, with occasional exacerbations and remissions,
for weeks and months.†
Diagnosis. Membranous sore throat is frequently confounded
with diphtheria, and remedies which have been employed more or
less successfully in the former malady may thus acquire an unmerited
reputation for efficacy in the treatment of the graver disease. The
differentiation of these two affections is often difficult. During the
vesicular stage, and when the local lesion is accompanied by an her-
petic eruption upon the mouth or face, the diagnosis is easy. When
the exudation is confined to the tonsils, the pillars of the fauces, and
the soft palate, and the constitutional symptoms rapidly subside
under treatment, there is a strong presumption that the malady is not
diphtheria. But occasionally, in membranous sore throat, the deposit
not only appears upon the posterior wall of the pharynx, but may
also extend to the air-passages, the systemic disturbance may be
* Cohen, op. cit., p. 105.
+ Ibid.
548
A SYSTEM OF MEDICINE.
severe and protracted, and the attack may be followed by paralysis of
the soft palate.* In these cases the resemblance to diphtheria is so
strong that an accurate differential diagnosis is impossible.
Prognosis.-Membranous sore throat is seldom a dangerous affec-
tion per se; but during an epidemic of diphtheria it may serve as a
starting-point for the latter disease, and in debilitated subjects it is
occasionally followed by gangrenous sore throat.
Treatment.—The majority of cases will terminate in recovery
without any treatment, but the duration of an attack can be shortened,
and the suffering greatly relieved, by the administration of properly-
selected remedies. Those which in my own experience have proved
most efficient are Kali bich., Lachesis, and the Iodides of mercury.
Belladonna, although apparently well indicated at the outset of the
disease, seems to act as a palliative rather than a curative agent.
Apis, Lycopodium, and Rhus tox. are occasionally useful. We append
the indications for the principal remedies:
Kali bich.-Accumulation of stringy, tenacious mucus in the throat; stitching
pains in the ears during deglutition; smarting, raw feeling in the posterior nares;
tendency of the exudation to extend to the air-passages; violent supra-orbital headache.
Lachesis.-The deposit is confined to the left side of the throat, or commences
on the left side, and extends to the right; solids are swallowed more easily than liquids;
the patient cannot bear the slightest pressure about the throat or neck; great dryness of
the throat, which is always worse after sleeping.
Merc. jod. flav.-The exudation is principally on the right side; thick yellow
coating at the base of the tongue; breath offensive; profuse salivation; coppery taste in
the mouth; uvula elongated and oedematous; cervical and submaxillary glands swol-
len; complexion sallow; aggravation from warm drinks.
Merc. jod. rub. is similar in many respects to Merc. jod. flav., but lacks the thick
yellow coating at the base of the tongue so characteristic of the latter remedy, and the
patches are confined principally to the left tonsil.
The throat should be protected by a silk handkerchief or a single
thickness of flannel, but external applications and astringent gargles
are unnecessary. In ordinary cases, the diet should consist of bread
and milk, or milk porridge. When the patient is much debilitated,
beef-tea and nutritive soups should be given. Alcoholic stimulants
are never required in this disease.
GANGRENOUS SORE THROAT.
Synonyms.-Putrid sore throat, Ulcerous sore throat, Phagedenic
sore throat, Malignant sore throat; Angina ulcerosa, Angina putris,
Angina gangrenosa, Cynanche maligna, Tonsillitis maligna, etc.
†
Mackenzie restricts this term to "primitive gangrene of the pha-
ryngeal mucous membrane originating independently of any other
malady," but the majority of writers use it to denote a form of pha-
ryngeal inflammation which may occur idiopathically, or may accom-
* Cohen, op. cit., p. 106.
† Op. cit., p. 53.
DISEASES OF THE ORGANS OF DIGESTION.
549
pany or follow other diseases, but is always either gangrenous from
the outset, or speedily leads to gangrene.
Before Bretonneau investigated the subject, there was a prevalent
belief that the disease was a common one; but the exhaustive re-
searches of that observer have conclusively proved that it is in reality
a rare affection, and that the malady described under this name by
ancient writers was diphtheria. The later observations of Trousseau
and Gubler also serve to confirm this view.
Etiology. Its predisposing causes are often obscure. It may su-
pervene upon diphtheria, typhoid fever, erysipelas, dysentery, glanders,
malignant pustule, or the acute exanthemata. It may also occur in
tubercular phthisis, even when the larynx and trachea are not involved,
and it may follow any variety of sore throat.* In some instances, ex-
posure to cold, or sudden suppression of perspiration, seems to act as
an exciting cause.
Anatomical Characters.—In the majority of cases the appear-
ance of the throat is not characteristic in the early stages, and the dis-
tinctive phenomena of the disease do not appear until the second or
third day. At first, the tonsils are swollen and livid, and the uvula,
soft palate, and pharynx are congested and oedematous. When the
morbid process is fully developed, ash-colored, dark or black, slightly
elevated patches can be seen upon the tonsils, the pillars of the fauces,
and the posterior wall of the pharynx, or, exceptionally, they may be
confined to the posterior surface of the palate, where they can be de-
tected only by rhinoscopic examination. These patches form eschars,
which ultimately become detached from the underlying tissues and
leave irregular ulcers, covered with an ichorous, offensive sanies. The
cervical lymphatics are often slightly tumefied and tender, but this
lesion is not invariably present. In favorable cases, the ravages of the
disease are confined to the parts first attacked. More frequently, how-
ever, the gangrene rapidly spreads in all directions, extending upward
to the mouth and posterior nares, and downward to the oesophagus,
larynx, and trachea. In some instances, fatal hæmorrhage is induced
by ulceration and perforation of the cervical bloodvessels; and in the
worst cases, sphacelated patches are found in the lungs, stomach, and
intestines.
Symptomatology. - Occasionally the disease begins like an
ordinary sore throat, with considerable fever, local inflammation, and
painful deglutition; but as a rule, the symptoms assume an asthenic
type from the outset, and pain and dysphagia are but slightly marked,
and may be absent. In all except the mildest cases, the breath has a
peculiar, fetid, gangrenous odor; this horrible fetor is present even in
the early stages, and persists throughout the whole course of the dis-
The tongue and the mucous membrane of the mouth are often
ease.
* Cohen, op. cit., p. 101.
550
A SYSTEM OF MEDICINE.
covered with a dark, pultaceous secretion. When the gangrene is fully
developed, there is a remarkable prostration of the vital forces, and
the patient falls into a state of collapse closely resembling the algid
stage of cholera. The features become pallid, pinched, and haggard,
the eyes have a glassy look, the voice is weak and muffled, there is
general coldness of the surface, the skin often presenting a bluish,
mottled appearance, and the pulse is slow and feeble. If the morbid
process extend to the lungs, there is copious hæmoptysis, and when
the alimentary tract is implicated, there is a profuse offensive diarrhoea.
Occasionally, in the worst cases, there is a simultaneous passive hæm-
orrhage from the nose, mouth, lungs, and bowels, and blood may also
be extravasated under the skin, forming petechial spots which soon
become gangrenous. Phlebitis of all the superficial veins has also
been observed. Death occurs from exhaustion, syncope, hæmorrhage,
or oedema of the glottis. In some instances the fatal termination is
preceded by coma, but more frequently consciousness is retained to
the last.
Diagnosis. In the early stages, and in those cases in which the
ulceration is confined to the posterior surface of the soft palate, and is,
therefore, out of the line of direct vision, this disease may be mistaken
by a careless observer for acute catarrhal sore throat, but can easily
be distinguished by the absence of severe pain, the marked prostration,
and the peculiar odor of the breath.
*
In later stages it may be confounded with diphtheria; but as Mac-
kenzie remarks, the resemblance between these two affections "is not
sufficiently great to lead an observant practitioner into error." In
diphtheria, the patches in the throat are, at first, whitish, and gradually
assume a darker hue, and the fetor of the breath is not marked until
the disease is fully developed; while in gangrenous sore throat the
patches are ash-colored, dark, or black, when they first appear, and
the peculiar fetid breath is one of the earliest symptoms. In diph-
theria, the cervical and submaxillary glands are always swollen; in
gangrenous sore throat, the glandular swelling is slight or entirely
absent.
Prognosis. The prognosis is always grave, yet in apparently hope-
less cases the patients sometimes survive. Recovery is rarely perfect,
however, for in the majority of instances the ravages of the disease cause
more or less permanent deformity. The uvula is generally destroyed,
and the soft palate either shares the same fate or contracts adhesions
to the pharyngeal walls, and in this way complete occlusion of the
retronasal portion of the pharynx may be produced. As the result of
this changed position of the parts, nasal respiration is abolished, smell
and taste are impaired, the voice loses its natural resonance, articula-
tion is difficult, and deglutition is often seriously embarrassed.
* Loc. cit.
DISEASES OF THE ORGANS OF DIGESTION.
551
Treatment.-Prof. Farrington * recommends Arsen., Bell., Carbo
veg., Conium, Kreos., Lach., and Silic. Prof. Lilienthal† suggests
Ammon. c., Arsen., Conium, Euphorb., Kreos., Lach., Merc., and Sulph.
Arsenic and Lachesis have the best clinical record.
Special Indications.-Arsenicum.-Great anguish, restlessness, and prostra-
tion; livid or bluish appearance of the throat; constant thirst for cold water, but takes
only a swallow at a time; the symptoms are all worse at night, especially after mid-
night, and are temporarily relieved by hot drinks.
Belladonna is sometimes useful in the early stages of the disease, when there
is intense congestion of the throat with flushed face, dilated pupils, throbbing of the
carotid and temporal arteries, and drowsiness with inability to sleep.
Carbo veg.-Rapid sinking of strength; cold breath; general coldness of the
surface, which may be covered with a clammy, sticky perspiration, yet the patient de-
sires to be fanned.
Kreasotum.-According to Prof. Lilienthal, this remedy "acts well in scrofu-
lous and lymphatic persons, with black softening and decomposition of the mucous
membrane, with atony and extension of the softening, especially toward the oesophagus."
Lachesis.—Dark red or purplish appearance of the throat; the disease begins
or is worse upon the left side; intolerance of the throat to the least touch or pressure;
great debility, with coldness of the extremities and feeble pulse; aggravation after sleep.
Destruction of the diseased tissue by bromine, caustic potassa, the
mineral acids, or the incandescent cautery, although highly recom-
mended by many writers, is of doubtful utility, and is applicable only
when the gangrene is superficial. If the ulceration extends deeply,
or occurs in close proximity to the cervical blood vessels, this treatment
is dangerous and impracticable.
When there is reason to apprehend perforation of the carotid, the
patient must be constantly watched, and if hæmorrhage occur, it must
be controlled by digital compression until the arteries can be properly
secured.
Beef-tea, eggs, milk, cream, and nutritious soup should be given in
large quantities and at frequent intervals, and in many cases alco-
holic stimulants are required. In the majority of instances the pa-
tient can swallow readily, and nourishment may, therefore, be admin-
istered by the mouth; when there is marked difficulty in deglutition,
nutritive enemata must be employed.
RETROPHARYNGEAL ABSCESS.
Synonyms.-Peri-pharyngeal abscess, Post-pharyngeal abscess,
Retro-oesophageal abscess, Peri-oesophageal abscess, Abscess of the
pharynx.
A collection of pus between the posterior wall of the pharynx and
the bodies of the cervical vertebræ is technically known as retropha-
ryngeal abscess.
Etiology. This affection may occur at all periods of life, but is
most frequent during infancy and childhood, and attacks by prefer-
* Studies in Materia Medica, Hahn. Monthly, vol. xv., p. 582.
† Homœopathic Therapeutics, p. 562.
Loc. cit.
552
A SYSTEM OF MEDICINE.
ence those already debilitated by scrofulosis or syphilis. It may arise
primarily from an idiopathic inflammation of the retro-pharyngeal
lymphatics or of the submucous connective tissue, the immediate
exciting cause being, usually, protracted exposure to a chilling atmos-
phere or a sudden change from extreme cold to undue warmth. It
may also supervene upon pharyngitis, acute tonsillitis, parotitis, sup-
purative inflammation of the external cervical lymphatics, caries of
the cervical vertebræ, scarlatina, measles, erysipelas, and pyæmia.
More rarely it is induced by wounds of the mucous membrane of the
pharynx produced by sharp foreign bodies-pieces of bone, splinters
of wood, pins, etc. All writers upon the subject, with the exception of
Bokai* and Mackenzie,† agree that, in the great majority of cases, the
disease is a secondary affection, and that its most frequent cause,
especially in adults, is cervical spondylitis terminating in caries.
Anatomical Characters.-The site of the abscess varies in dif-
ferent cases. Usually the swelling can be seen on one side of the
pharynx opposite the glottis, but occasionally it is concealed behind
the posterior nares or behind the oesophagus. It may be no larger
than a pigeon's egg, or it may fill the whole pharyngeal cavity, and
even project in front of the soft palate. Its walls may be thin and
fragile, or hard and almost cartilaginous. The overlying mucous
membrane is reddened and shining from tension, but seldom presents
any evidence of severe inflammatory action; late in the disease a few
yellow spots appear upon its surface, indicating the formation of pus.
In the majority of cases the abscess discharges its contents into the
pharynx, but occasionally the purulent fluid burrows in various direc-
tions, in some instances making its exit in the parotid region, in
others gravitating toward the thoracic cavity, and perforating the
œsophagus, trachea, or pleural sac.
Symptomatology.-The onset of the malady is generally insid-
ious. In secondary abscesses the precursory symptoms are those of
the primary disease; but in idiopathic cases, with the exception of
pain and soreness in the throat and slight difficulty in swallowing,
there is nothing to excite suspicion in the early stages. Later, the
symptoms become more pronounced. The pain and soreness increase
and are aggravated by motion of the neck or by pressure upon the
larynx. The throat is swollen externally upon the side corresponding
to the site of the abscess. This tumefaction usually occupies the
natural depression between the angle of the jaw and the sterno-cleido-
mastoid muscle, but sometimes involves the whole side of the neck,
and may even extend to the posterior cervical region. The neck is
stiff, and there is a marked immobility of the head, which is either.
retracted or, when the abscess occupies a lateral position, inclined
toward the healthy side. In some instances there is a rigid contrac-
† Op. cit., p. 34.
* Jahrbuch für Kinderheilkunde, 1876.
DISEASES OF THE ORGANS OF DIGESTION.
553
tion of the sterno-cleido-mastoid, simulating torticollis. Usually, there
is a pronounced febrile action, with alternation of heat and rigors or
merely general chilliness. There is great restlessness, the mouth is
hot and dry or filled with mucus, and the tongue is heavily coated.
Convulsions are frequent in nursing infants, and facial paralysis has
been observed by Bokai* in three cases.
A marked feature of this disease is the serious interference with the
degluto-respiratory functions. The dysphagia varies from simple.
inability to swallow solids to complete aphagia. Respiration is
labored and stertorous during both inspiration and expiration; the
voice is muffled, feeble, or indistinct, and there is snoring during
sleep. Cough is slight or absent. The dyspnoea increases with the
growth of the abscess; the patient is obliged to maintain an erect or
semi-reclining posture; and suffocative attacks are induced by cough-
ing, swallowing, and by any attempt to bend the head forward or to
assume a horizontal position. Cyanotic symptoms supervene, and,
unless the abscess is opened or ruptures spontaneously, death ensues
from asphyxia. The case may also be complicated by oedema of the
larynx and suppuration of the submaxillary glands.
When the abscess is situated entirely behind the oesophagus, the
symptoms vary slightly from those above described. There is less
relief in the sitting posture; the lateral swelling of the neck is lower
down, further forward, and is most prominent on the left side; food is
not ejected through the nostrils, but part of it is swallowed and part
passes into the larynx, causing paroxysms of cough; pressure upon
the larynx induces attacks of asphyxia, but causes less pain than
pressure upon the oesophagus, and the voice is "shrill and piping,
and comparable to that of a duck.Ӡ
Finally, there are exceptional cases in which many or all of the
characteristic symptoms of the disease are absent. When the abscess
occupies an exactly central position, there is usually no external
swelling of the neck; when it is located behind the posterior nares,
there may be dysphagia, but there is no marked dyspnoea; and when
it is small and has an extreme lateral site, or forms between the
sheaths of the muscles and the membranous walls of the pharynx, the
suppurative process may run its course without fever or any serious
obstruction in swallowing or breathing. In some cases, dependent
upon caries of the cervical vertebræ, the first noticeable symptom may
be a sudden expectoration of purulent matter, mingled with small
pieces of carious bone.‡
The duration of the disease varies according to the location and size
of the abscess, the rapidity of its growth, the direction in which it
extends, and the severity of the accompanying inflammation. In the
* Jahrbuch für Kinderheilkunde, 1876.
Meigs and Pepper, op. cit., p. 351.
† Cohen, op. cit., p. 247.
554
A SYSTEM OF MEDICINE.
worst cases death may occur as early as the second or third day;
when the malady pursues its ordinary course, it may last from one
to three weeks; and when the abscess is small, grows slowly, has a
lateral or downward extension, and exerts but slight pressure upon
the air-passages, the case may be prolonged for months.
Diagnosis.-Retropharyngeal abscess may always be suspected
when a child has paroxysms similar to those of croup, but less dis-
tinctly remitted, associated with well-marked dysphagia. These
symptoms, however, are not conclusive. Positive proof of the exist
ence of the disease can be obtained only by ocular inspection and
digital exploration. When the abscess is located behind the posterior
nares or behind the oesophagus, it is out of the line of direct vision,
and can be detected only by the aid of the rhinoscope or the laryngo-
scope; but when it occupies its usual site, if the mouth be widely
opened and the tongue strongly depressed, the swelling, or at least
some portion of it, can be seen pushing forward the posterior pharyn-
geal wall and encroaching upon the cavity of the pharynx. The fore-
finger, carried down over the base of the tongue, encounters a hard,
elastic, or fluctuating tumor, which, in many cases, can also be felt.
externally. By this method a positive diagnosis may often be made
when ocular inspection affords only negative or uncertain evidence.
In a large proportion of the reported cases, the disease was not rec-
ognized during life, but was mistaken and treated for some other affec-
tion. The maladies which most resemble it are membranous croup
and oedema of the larynx. From the former it may be distinguished
by the dysphagia, the aggravation of the dyspnoea in the horizontal
position, the sensitiveness of the larynx to pressure, and the tone of the
voice, which may be muffled or indistinct, but never has the hoarse or
whispering sound characteristic of croup.
In oedema of the larynx, the obstruction to breathing occurs sud-
denly, and is most marked during inspiration, while in abscess there
is usually a period of several days before the respiration is seriously
affected, the dyspnoea develops gradually, and both inspiration and
expiration are equally difficult. It must not be forgotten, however,
that the two affections may coexist.
In infants the reflex cerebral phenomena may so completely mask
the primary lesion that the disease may be mistaken for meningitis.
The diagnosis is often difficult, but if an accurate history of the attack
can be obtained, the priority of the pharyngeal affection will indicate
the true nature of the malady. In all cases of doubtful diagnosis the
crucial test is the evidence afforded by inspection and palpation.
Prognosis.—In neglected or mismanaged cases, most of the patients
die of apnoea or cedema of the larynx; but when the disease is recog-
nized early and properly treated, the majority recover. Abscesses
which form behind the oesophagus usually terminate fatally. The
prognosis is also unfavorable when the pus perforates the oesophagus,
DISEASES OF THE ORGANS OF DIGESTION.
555
trachea, or pleural sac. In rare instances death may ensue from erosion
of the internal carotid artery. When a large abscess is punctured or
ruptures spontaneously, the purulent matter sometimes floods the air-
passages and causes instant asphyxia.
When the disease is dependent upon caries of the cervical spine, re-
covery is occasionally effected after the exfoliation and discharge of
portions of the vertebræ; but in the great majority of these cases, even
when the malady is properly treated, the patients ultimately perish.
When the abscess produces extensive caries of the intervertebral car-
tilages, rupture or incision of the sac may be followed, according to
Dr. Allen,* by dislocation of the vertebræ and fatal compression of
the spinal cord.
Treatment.—When the disease develops idiopathically, it can gen-
erally be aborted in the incipient stage, according to Duncan,† by the
timely administration of Belladonna or Kali bich. Raue‡ considers.
Hepar and Silic. the main remedies, and recommends Aurum, Bell.,
Lach., Lycop., Merc., Nitric ac., and Phos., if fluids regurgitate through
the nose when the patient attempts to swallow.
In the majority of cases, medical aid is not summoned until the
malady has reached a point where all efforts to prevent suppuration
are likely to prove futile. The indications for treatment under these
cirumstances are to hasten the suppurative process by such remedies
as Hepar, Merc., or Silic., and to promptly evacuate the pus as soon as
fluctuation can be detected.
The abscess may be opened with a lancet, scalpel, bistoury, or the
needle of the aspirator; when its walls are thin, they may be punctured
with the finger-nail or ruptured by the pressure of the finger; and
when the swelling points externally, it may be opened from the outside.
Care must be taken not to injure the vertebræ or to wound the cervical
blood vessels, and caution is especially necessary when the abscess lies
in close proximity to the internal carotid artery. If the sac refill, it
must be emptied by gentle pressure from below upward. Usually, the
abscess rapidly heals after the evacuation of the pus, but occasionally
there remains an ulcer which slowly heals by granulation.
Tracheotomy is sometimes necessary when the abscess forms behind
the oesophagus, or when there is cedema of the glottis which refuses to
yield to Apis or Merc. corr.
Stimulants are rarely needed, but the patient's strength must be
sustained by nutritious liquid food, given by the mouth, or, where
there is inability to swallow, by the rectum.
Diffuse InflaMMATION OF THE CONNECTIVE TISSUE OF THE NECK.
Synonyms. Angina Ludovici, Morbus Ludovici, Cynanche cel-
lularis maligna, Cynanche sublingualis rheumatico-typhoides, Pseudo-
+ Diseases of Children, p. 292.
* N. Y. Jour. Med., Nov., 1851.
‡ Pathology and Therapeutics, p. 112.
556
A SYSTEM OF MEDICINE.
erysipelas subtendinosum colli; Diffuse cervical abscess, Diffuse cer-
vical phlegmon.
This formidable disease is, fortunately, rare, and is confined almost
exclusively to adults. It sometimes presents itself as an idiopathic
affection. In other cases it is secondary to inflammatory affections of
the hyoid bone, inferior maxilla, or larynx. It has also been known
to occur as a complication of typhoid and puerperal fevers and the
acute exanthemata, and in some instances has followed wounds of the
neck.
Anatomical Characters.-The whole cervical region may be in-
volved from the parotids to the clavicles. The inflammatory process.
begins in the connective tissue, but soon extends to adjacent structures.
It may terminate in resolution, but more frequently passes into sup-
puration, which, in the majority of cases, ultimately becomes gangre-
nous. In the worst forms of this disease the different planes of cellu-
lar tissue, one after another, are destroyed; the cervical lymphatics.
and the submaxillary, parotid and thyroid glands, may slough; and,
finally, the cervical muscles, and even the larynx, may undergo degen-
erative changes. The affected parts are infiltrated with a sanious, offen-
sive pus,
which usually makes its exit upon the cutaneous surface or
into the mouth, but in some instances gravitates into the mediastinum
or perforates the œsophagus or the trachea.
Symptomatology.-The initial symptoms are headache, loss of
appetite, dysphagia, and slight fever. A hard, painful swelling next
appears on one or both sides of the neck in the supra-hyoid region,
and, in some cases, can be felt in the floor of the mouth; the skin re-
tains its normal color and is freely movable. The tumefaction rapidly
increases in size, and in the course of a few days may project beyond.
the chin. The overlying integument is now tense, brawny, and firmly
adherent, and the mucous membrane of the whole oral cavity is swol-
len and reddened. The face is oedematous, the head is retracted, the
floor of the mouth is pressed upwards, the mobility of the tongue is
lost, the jaws are nearly or completely closed, the breath is offensive,
and there is a profuse flow of fetid, viscid saliva. Speech is indistinct,
and deglutition difficult or impossible. The pressure of the tumor
upon the larynx and trachea causes serious embarrassment of respira-
tion, which may increase to urgent dyspnoea and even asphyxia; and
the compression of the internal jugular vein induces hyperæmia of the
brain, headache, vertigo, and delirium. Edema of the larynx may
also occur. The fever at this stage may be slight or severe.
lution takes place, the symptoms gradually subside, but the process
of resorption is slow, and a hard swelling remains for weeks.
If reso-
Where the disease passes into the suppurative stage, the tumor
softens, the overlying skin becomes congested and, as the pus ap-
proaches the surface, shows an erysipelatous blush, or presents a
•
DISEASES OF THE ORGANS OF DIGESTION.
557
glazed appearance; fluctuation can be detected, in the majority of cases,
by careful palpation, and if gangrene supervene, there is well-marked
crepitus on pressure. The constitutional symptoms now assume an
adynamic or typhoid form. The patient, unable to obtain any re-
freshing sleep, and exhausted by constant suffering, rapidly loses flesh
and strength, while the toxæmic influence of the fetid secretions helps
to still further depress the vital power.
According to Cohen,* the duration of an idiopathic case, terminating
in recovery, is from ten to twenty days, while secondary cases pursue
a more chronic course. When the disease proves fatal, death may
occur in a few days, or the suffering may be prolonged for two or three
weeks.
Diagnosis. This malady is not likely to be confounded with any
other affection. The symptoms are so striking and peculiar that an
error in diagnosis is hardly possible.
Prognosis. This is always grave. Recovery may be expected
when the inflammation shows a tendency to terminate in resolution,
or the suppuration is of limited extent; but, unfortunately, these are
the exceptional cases. When suppuration and gangrene are extensive,
a few patients may survive, but the great majority die of exhaustion
or pyæmia. If the abscess burst into the mediastinum, oesophagus,
or trachea, the result is almost invariably fatal. Death may also occur
from œdema of the larynx, from mechanical asphyxia induced by the
pressure of the tumor upon the air-passages, or, in some cases, as the
late Dr. Sidellt has recently demonstrated, from hæmorrhage due to
ulceration and erosion of the tunics of the cervical blood vessels by a
peculiar species of inflammatory ramollisement." The disease may be
followed by fistulous ulcerations, by cicatricial contractions which in-
terfere with the mobility of the neck, and, in some cases, by caries and
necrosis of the hyoid bone and the inferior maxilla.
(C
Treatment.—Homœopathic literature is silent upon the thera-
peutics of this affection; but the remedies which, according to their
pathogeneses, ought to prove reliable are: Anthracinum, Arsen., Arsen.
iod., Bell., Crotal., Hepar, Kreos., Lach., Merc., Phytol., Rhus tox., Silic.,
and Tarantula cubensis.
Of these, Antrac., Arsen. iod., Bell., and Rhus tox. correspond to the
inflammatory stage; Hepar, Merc., and Silic. to the suppurative period;
and Arsen., Crotal., Kreos., Lach., Phytol., and Tarant. cub. to the gan-
grenous form of the disease.
Apis or Merc. corr. will be indicated when there is oedema of the
larynx, and Carbo an. will be required for induration remaining after
resolution.
The patient's strength must be sustained by a nourishing diet, and
if aphagia exist, by nutritive enemata. Stimulants should be freely
* Op. cit., p. 690.
† Amer. Jour. Medical Sciences, Oct., 1883.
558
A SYSTEM OF MEDICINE.
used when necessary. In the early stages the external application of
ice is sometimes beneficial; when suppuration is inevitable, hot fomen-
tations are indicated to hasten the process. As soon as fluctuation
can be detected, the pus should be evacuated by a free incision, or,
when this is hazardous, by a careful dissection of the tissue of the
neck. Strict antiseptics and thorough drainage are absolutely essen-
tial. All soiled dressings must be destroyed or disinfected.
When asphyxia is imminent from oedema of the larynx, or from
compression of the larynx and trachea, and free incisions fail to afford
relief, tracheotomy is imperatively demanded. The operation is ex-
ceedingly difficult in these cases, and the tracheotomy-tube must be of
extra length, or, as Cohen* suggests, a section of rubber tubing may
be used as a substitute.
When hæmorrhage occurs, Dr. Sidell advocates the following treat-
ment: The abscess cavity must be freely opened, the clots turned out,
and the bleeding vessel ligated on each side of the opening in its walls.
If the ligature cut through the softened tunics, the actual cautery
must be applied. When neither of these methods is applicable,
digital compression of the common carotid should be tried, and if this
fail, ligation of that artery affords the only hope of saving life.
DISEASES OF THE MUCOUS MEMBRANE OF THE MOUTH.
BY CLARENCE M. CONANt, m.d.
THRUSH.
Synonyms.-French, Aphthe; German, Mundschwamm.
Definition. A circumscribed inflammation of single or numerous
spots on the mucous membrane of the mouth, characterized by a
white exudation which, whether forcibly removed or spontaneously
exfoliated, leaves an ulcer in the subjacent mucosa.
History. In popular parlance all those ulcerations of the mucous
membrane of the lips, tongue, and cheeks, which are characterized by
the white flaky membrane and the excavated underlying ulcer, have
been styled thrush. Nor was it until 1842 that the histological nature
of these white patches was understood. In that year Gruby first dis-
covered a minute fungus in them, which he styled Aphthaphyte, from
which is derived our word aphtha. For that reason, remarks W.
Fairlie Clarke, it would seem desirable to restrict the term aphthæ to
those exudations in which this fungus is found; for there may exist
in the mouth a simple stomatitis or a dyspeptic ulceration in whose
exudation this fungus does not exist. This fungus was recognized by
Robin as belonging to the genus oidium, and was named by him oidium
albicans.
* Op. cit., p. 691.
DISEASES OF THE ORGANS OF DIGESTION.
559
Etiology.-Thrush is usually seen in the last stages of wasting
diseases, or in the new-born or the extremely aged. The fact that
gastric, and sometimes intestinal, disturbances usually accompany it,
would seem to point to disorders of the digestive apparatus as a cause.
Pathology.-Genuine aphthæ originate in small patches of a white,
curdy, or flake-like membrane, forming upon the mucous membrane
of the mouth, and firmly adherent to it. These patches tend to extend
and coalesce, so as to form a continuous white coating. Under the
microscope the exudation is seen to depend upon a minute fungus,
the oidium albicans. This is found growing upon the mucous mem-
brane, in intimate association with its epithelium, arising in delicate
horizontal threads, composed of homogeneous cells, much elongated,
and placed end to end. The upmost cells expand into oval bodies,
which, falling off, become transplanted and, taking root elsewhere in
the mucous membrane, form a new patch or extend the old one.
This white patch or pseudo-membrane is then seen to consist of these
filaments, tangled together and mixed with debris of scattered cells,
epithelium, and spores of that other fungus found in the angle be-
tween the teeth and the gums, the leptothrix buccalis. When this
white patch is removed, or even spontaneously shed, the mucous.
membrane comes with it, and a characteristic ulcer is observed in the
subjacent papillæ. This ulcer is small, flat, and of regular geomet-
rical shape, round or oval; its base is soft and smooth, with a yellow-
ish or ashy slough; its edges are well defined, but not thickened or
elevated, and the whole is surrounded by a red areola. As the patches
seem to develop in successive crops, so likewise do the ulcers. A
dyspeptic thrush, sometimes proceeding to ulceration, is frequently
seen, but this is not aphthæ proper, as it does not arise from, nor con-
tain, the fungus oidium albicans. This form will be discussed under
"stomatitis."
Symptomatology.-Raue lays much stress upon an acid condi-
tion of the system in general, and an intensified acidity of the buccal
fluids in particular, as a forerunner and cause of thrush; when, there-
fore, in bottle-fed infants, or in poorly nourished persons, unusual
dryness, heat, and redness of the mouth are observed, and increased
viscidity and acidity of saliva, an attack of thrush may be expected.
In a few hours initial spots of white flakes, of the size of a pin's
head, may be detected under, or upon the edges of, the tongue (a
favorite location) or upon the cheeks; these rapidly multiply and
coalesce, so that ten or twelve hours may suffice to bring the disease
almost to its height. The membrane remains firmly adherent until
the third or fourth day, when the ulceration is seen occupying the
same spots at first covered by the white pseudo-membrane. Or more
frequently the mouth exhibits successive stages or crops of the spots;
some show evidence of inflammation, and are dotted with minute.
560
A SYSTEM OF MEDICINE.
white flecks, others are well covered with the white adherent fur; still
others, denuded of the exudation, show the papillæ raw and red; and
again we see them in the last stage, exhibiting the characteristic ulcer.
The ovoid tops of the filaments composing the oidium albicans take
root readily and grow if placed upon any mucoid surface; thus the
flakes may be grafted upon the nipple of the nursing mother; or,
when swallowed by the child, may develop in the stomach and bowels,
appearing at the anus as an intertrigo. This intestinal development
gives rise to an actual follicular enteritis. Fever, nausea, vomiting,
and often diarrhoea, increase the discomfort caused by the heat and
dryness of the mouth, which alone are quite enough to occasion much
thirst and uneasiness. The disease may continue for an almost indefi-
nite length of time, the strength and powers of endurance of the
patient being its only limit, unless checked by treatment. The termi-
nation is favorable, save when the thrush is a symptom occurring in
the last stages of wasting diseases.
Treatment.—As an acid state of the system in general, and of the
saliva in particular, favors the development of thrush, scrupulous clean-
liness should be insisted upon in the care of bottle-fed babies. Abso-
lutely sweet wholesome food, and plenty of it, is essential, and should
be secured by careful and frequent washing of all the bottles, tubes,
spoons, and other utensils employed in feeding. If the infant is
suckled by its mother, her milk should be examined, and any varia-
tions in it, or in her health, should be corrected. If these deviations.
from normal standards are very wide, or not easily and speedily set
right, a wet-nurse should be had, or the child weaned and fed arti-
ficially.
When thrush occurs in old people, or in the course of wasting dis-
eases, the aphthous fungus seems to flourish with unusual vigor, and a
disinfectant is often necessary, not alone to destroy the growth and to
prevent its reproduction, but also to overcome the fœtor so often ob-
served. For this purpose Sir William Jenner advises a weak solution
of the sulphite of soda in water, a drachm to an ounce. A weak solu-
tion of carbolic or sulphurous acid, or of Condy's fluid, or of the
various chlorides, is also recommended.
Remedial.-Aethusa.-Painful aphthæ in the mouth of infants who cry much,
as from colic; vomiting of milk in lumps; diarrhoea of undigested stools.
Arsenicum album.-Aphthee in the mouth of adults or infants, becoming
bluish or livid. Intense burning; great exhaustion: characteristic diarrhoea.
Arum triph.-Buccal cavity raw, sore, and bleeding. The mouth burns; in-
fants refuse drink, and cry when it is urged or even offered. Acute stomatitis, with
great swelling of the lips and superficial ulceration.
Mate
Baptisia. Aphthæ in the last stages of phthisis and of nursing infants. Putrid
ulceration of the mouth, with salivation and well-developed ulcers. The thrush ex-
tends through the alimentary canal, giving rise to an offensive, watery, excoriating
diarrhoea, which may even become slimy and bloody.
Borax.-Infantile aphthæ which bleed easily; great heat and dryness of the
mouth.
DISEASES OF THE ORGANS OF DIGESTION.
561
Helleborus.-Mouth full of flat yellow ulcers with elevated gray edges or red
swollen bases. Carrion-like odor; salivation; glands under the jaw and on the neck
swollen.
Hydrastis.-Follicular inflammation and dyspeptic ulcerations, with exceed-
ingly tenacious mucus in the mouth. Nursing women, weakly children, and debili-
tated persons. Marasmus. Chronic gastric catarrh. Constipation.
Mercurius.-Aphthous ulceration of the mouth; copious, fetid, ropy saliva-
tion; scorbutic gums; large blisters in the mouth; ulceration of the glands, ducts,
and their orifices; burning pains at night, burning diarrhoeic stools.
Muriatic acid (or Nitro-muriatic acid).-Stomatitis of nursing babies; large
irregular deep ulcerations; fetor of breath.
Natrum mur.-Vesicles and ulcers in the mouth and on the tongue, smarting
and burning when touched by the food.
Nitric acid.-Mucous membrane of the mouth swollen and ulcerated; pricking
pains, especially after the abuse of Mercury. Fetid and acrid saliva, which causes.
sores on the lips, chin, and cheeks.
Nux vomica.-Dyspeptic and aphthous ulcerations in small spots; putrid odor
from the mouth; bloody saliva; gums foul, swollen, and ulcerated. Constipation.
Staphisagria.-Stomatitis. Aphthous blisters, changing into canker sores,
with a bluish-red or yellowish bottom.
Sulphur.-Blisters in the mouth. "When the thrush has gone through the
child."
Sulphurous acid.-Aphthous mouth, and gums yellowish and painful. After
Borax. Stomatitis of nursing women.
Also Calcarea carb., Carbo veg., Chamomilla, Cornus cir., Eupato-
rium, Hepar, Lachesis, Phytolacca, Veronica.
A weak solution of the appropriate remedy may be locally applied,
frequently to the greatest advantage.
STOMATITIS.
Synonyms.-French, Stomatite; German, Mundschleimhautent-
zuendung.
Definition.—An inflammation and, sometimes, ulceration of the
mucous membrane of the mouth, resembling thrush or aphthæ, but
distinct from it pathologically.
Ætiology.—Like genuine aphthæ, stomatitis arises in debilitated
infants or adults, dyspeptics and children convalescing from eruptive
fevers affording many cases.
Pathology. The first stage of stomatitis consists in an inflamma-
tion of the mucous follicles of the mouth and a mucoid exudation in
white patches. This exudation is histologically distinct from that con-
stituting true aphthæ in that it does not contain any fungus or organized
growth, although it is almost identical with it in appearance. This is
called follicular stomatitis, there being as yet no breach of surface.
Should the inflammation remain unchecked, the mucous exudation is
exfoliated, the follicles rupture, and form small ulcers covered with a
yellow or gray slough; often these coalesce and form large ulcerated
spots. This is ulcerative stomatitis or dyspeptic thrush, whose ulcer,
although resembling the true aphthous ulcer, differs from it in essential
features, notably in degree of intensity.
VOL. I.-36
,
562
A SYSTEM OF MEDICINE.
Symptomatology.-In follicular inflammation the mouth be-
comes hot, dry and tender; the follicles are seen to be red and swollen;
salivation occurs, and sometimes diarrhoea. So far, there is no solution
of continuity, but if the morbid process now becomes suppurative,
the white or ash-colored patches are thrown off, and little ulcers are
formed in the burst follicles. These sometimes remain few and dis-
tinct, but more often they spread, and rapidly coalesce.
Varieties. Stomatitis may be follicular, ulcerative or gangrenous.
The first two have been discussed; the last will be considered under
"Gangrene of the Cheeks."
Diagnosis. The only differential question which is likely to arise
lies between true aphthous thrush and simple stomatitis. Nor can we
certainly distinguish them save by the aid of the microscope, which
in true aphtha will show the oidium albicans. Fortunately, the diag-
nosis is of more theoretical than practical value, since the homeopathic
treatment is very similar.
Prognosis. Follicular stomatitis is never a serious complaint, but
its advanced form (ulcerative) may occasion great annoyance by its
persistence, and may even occasion death by exhaustion. True
aphthous thrush is always to be dreaded; it frequently hastens death
in consumption, typhus, and other diseases marked by great waste;
occasionally it destroys a nursing woman, and not a few infants suc-
cumb to its torments.
Treatment.-Stomatitis, follicular and ulcerative, so closely re-
semble thrush that we have included the treatment of all under the
common head, Thrush.
GANGRENE OF THE CHEEKS.
Synonyms.-Gangrenous stomatitis, Cancrum oris, Noma.
Definition.—A malignant ulceration of the cheeks, arising in their
mucous surface, and ending in destruction of the affected parts by
gangrene.
Etiology. Severe attacks of profound diseases which impoverish
the blood, such as scarlet fever, measles, small-pox and typhus in
children, and typhus and puerperal fever in adults, predispose to
noma. It is not often seen outside of public institutions.
Pathology.—William Aitkin and C. G. Raue describe cancrum oris
as originating from one small vesicle, or more, situated inside the cheek
and containing a pale red, grayish or brown ichor. Raue remarks of
the vesicle: "It bursts so soon that its formation is mostly overlooked."
And so good authorities as W. Fairlie Clark, Dr. West and Joseph
Coats describe as the initial process the ulcer arising from the rupture
of this blister. Nevertheless, we think it is in this vesicle and its fluid
contents that pathologists must seek for the exact histological cause
DISEASES OF THE ORGANS OF DIGESTION.
563
A
and nature of that unknown and yet confessedly specific poison from
which is developed this destructive and fatal morbific process.
Coexistent with, and subsequent to, the formation of this blister is
an intense diffuse inflammation of the whole cheek, while on its site
arises a phagedenic ulceration, speedily becoming gangrenous and
sloughing away. Should the patient survive long enough, the whole
cheek, and even the ear and eyelids, become sphacelated, while in ex-
treme cases necrosis of the jaws, gangrenous pneumonia, and general
septicæmia rapidly succeed each other.
Symptomatology. As described above, gangrene of the cheeks.
begins as a small blister or vesicle on the inner side of the cheek, near
the angle of the mouth. This vesicle contains a pale-red or brownish
fluid, and very quickly bursts, leaving on its site a dirty, foul, deep
ulceration. The whole cheek is now seen to be swollen, its outer sur-
face red, tense, and shining as if oiled. The redness soon becomes
marbled and darker, while a central spot in the cheek externally, op-
posite to the ulcer in the mouth, becomes very hard and dark colored,
and soon is covered with a black crust or scab, the centre of a gangre-
nous slough which speedily falls out, leaving a hole in the cheek whose
edges are gangrenous ulcerations. The glands of the neck (and some-
times the whole lymphatic system) become poisoned, enlarged and
tender; prostration is complete, colliquative diarrhoea sets in, and the
patient speedily dies of exhaustion. Should exuberant vitality or care-
ful nursing and treatment buoy up the system, an extension of the
gangrenous process to the jaws, eyelids and ears may be expected; the
teeth fall out, and even the tongue, palate and tonsils are invaded, the
whole process occupying only a very few days.
Prognosis.—Always doubtful, and usually unfavorable.
Treatment. The diet is of great importance. Milk, beef tea and
other nourishing fluids should be fed often and in small quantities.
The mouth should be frequently rinsed with a warm antiseptic solu-
tion. Permanganate of potash, carbolic acid, and corrosive sublimate
are recommended. A poultice on the cheek, continued until the slough
falls out, will prove of advantage.
Arsenicum.-Sore lips and ulcers in the mouth. Dryness of the mouth with
violent thirst. Painful blisters on the inside of the cheek. Gangrenous sores.
Carbo veg.-Humid gangrene, and collapse. Bleeding ulcerations.
Cinchona.-Salivation. Gangrene of the throat. Black, humid gangrene.
Hæmorrhages from the mouth.
Helleborus.-Corners of the mouth sore. Flat, yellow ulcers on the cheeks
with elevated gray edges, red. swollen base, and carrion-like odor; salivation.
Lachesis.-Bad odor from the mouth; bluish or black ulcerations; gangrene.
Mercurius dulcis.-Rapidly spreading gangrenous destruction of the lips,
cheeks, gums and jaws.
Muriatic acid.-Deep, painful, putrid ulcers in the cheeks. Foul breath.
Great nervous prostration; typhoid condition.
Nitric acid.-Ulcers in the corners of the mouth and in the cheek. Putrid odor
from the mouth.
564
A SYSTEM OF MEDICINE.
Phosphoric acid.—Cancrum oris following measles in syphilitic children.
Painless glandular swelling; painless diarrhoea. Gnawing pains.
Silicea.—Mouth gangrenous; perforating ulceration of the palate.
Sulphur.-Blisters in the mouth. Foul ulcerations surrounded with pimples.
B. DISEASES OF THE ESOPHAGUS.
BY W. T. LAIRD, M.D.
INFLAMMATION OF THE ESOPHAGUS.
Synonyms.-Esophagitis, Dysphagia inflammatoria.
Inflammation of the oesophagus is a comparatively rare affection.
It may affect the whole extent of the tube or only a limited portion.
The inflammatory process may be acute or chronic and, in some in-
stances, may terminate in ulceration or abscess.
Etiology. Catarrhal inflammation of the oesophagus is usually
caused by exposure to cold and damp; by improper regimen, espe-
cially the habitual use of very hot or very cold food; and by the ad-
ministration of irritant medicine. It may arise from the extension of
gastric and pharyngeal catarrh, thrush and stomatitis, or it may ac-
company measles, scarlatina and typhoid fever. It may also be in-
duced by passive venous congestion dependent upon chronic cardiac.
and pulmonary disease, or upon the pressure of tumors, aneurisms,
etc., upon the tube. Corrosive œsophagitis is due to the deglutition of
caustic alkalies, strong mineral acids or boiling water.
. Membranous, exudative or croupo-diphtheritic oesophagitis occurs.
in connection with croup, diphtheria, croupous pneumonia, typhus
fever, tuberculosis, carcinoma, pyæmia, and the acute exanthemata.
Pustular esophagitis is caused by small-pox or by the abuse of tartar
emetic. Ulceration and abscess may result from the impaction of
foreign bodies, or from corrosive or catarrhal inflammation.
Anatomical Characters.-In acute catarrhal oesophagitis the
mucous membrane is congested, friable, and covered with thick mucus;
in chronic cases it is hypertrophied, and presents a brownish or grayish
appearance. In corrosive inflammation the affected parts are black
and gangrenous, while the surrounding portions are intensely congested
and extensively infiltrated with serum. In the membranous variety
the œsophageal walls are greatly thickened by infiltration of the
mucous and submucous tissues, and the interior of the tube is lined
for some distance with strips or patches of exudation. Pustular œso-
phagitis is characterized by the formation of small pustules which
burst and leave superficial erosions; when the disease is due to large
doses of tartar emetic these pustules are confined to the lower portion of
the tube. Ulceration is usually limited to the mucous membrane, but,
in some instances, it may penetrate to the underlying structures.
DISEASES OF THE ORGANS OF DIGESTION.
565
Symptomatology.-The œsophagus possesses so little sensibility
that mild cases of this disease often escape recognition. Severe
inflammation is characterized by a sensation of constriction and
dull, aching, stinging, burning or lancinating pains behind the ster-
num or between the scapula, and when the upper portion of the tube
is involved, this pain is increased by external pressure. The affected
parts are so exquisitely sensitive that even the passage of saliva in-
creases the suffering, and the patient, although tormented by constant
thirst, often refuses to swallow. In some instances every attempt to
take nourishment produces spasm, retching and vomiting; in others
the food is partially swallowed and then regurgitated, covered with
mucus, pus, blood, or shreds of false membrane. The dysphagia,
which is due in part to the swelling of the mucous membrane, but
more especially to the inflammation and infiltration of the œsophageal
muscles, is always aggravated in the recumbent position, and may in-
crease to complete aphagia. The tongue is heavily coated, the breath
is fetid, and there is profuse salivation. Diarrhoea and other symp-
toms of deranged digestion are often present; and in corrosive inflam-
mation there is usually coincident stomatitis, pharyngitis, or gastritis.
In the worst cases there is fever with great mental anxiety, headache,
pale, distorted face, and small, feeble pulse; and in children, reflex
irritation of the pneumogastric nerve may give rise to convulsions.
In chronic œsophagitis the symptoms are similar to those above de-
scribed, but milder and more protracted.
Diagnosis. In many instances the diagnosis is difficult. Mild
cases present no characteristic features by which they can be recog-
nized during life; pustular esophagitis has no distinct significant.
symptoms, and in the membranous variety the pain and dysphagia
are obscured by the graver phenomena of the accompanying affec-
tions, and the disease, therefore, usually escapes detection unless masses
of the exudation are expelled by hawking or vomiting. In severe or
moderately severe catarrhal or corrosive inflammation the diagnosis.
is comparatively easy. A sudden discharge of pus and pieces of
necrosed membrane is indicative of abscess. In some cases of chronic
ulceration the permanent interference with deglutition might lead to
the suspicion of stricture, but the diagnosis is easily established by
the passage of the sound, which encounters no obstruction and, when
withdrawn, is often covered with mucus, blood, or pus.
Prognosis. The prognosis depends upon the cause of the disease,
and to some extent upon the severity of the inflammation. It is
favorable in ordinary acute catarrhal oesophagitis and pustular
œsophagitis from tartar emetic. It is unfavorable in membranous
œsophagitis, the pustular oesophagitis of variola, and in the extensive
inflammation and sloughing caused by corrosive substances. Intense
acute catarrhal œsophagitis, chronic œsophagitis, moderately severe cor-
566
A SYSTEM OF MEDICINE.
rosive inflammation, abscesses and ulceration are usually followed by
stricture; chronic œsophagitis may also cause dilatation of the tube,
and abscesses which burst externally produce fistula. Death occurs.
in some instances from perforation or rupture of the oesophagus.
Treatment. In cases of corrosion of the œsophagus, if the patient.
be seen immediately after the accident, the proper chemical antidotes
should be promptly administered-vinegar and water if caustic alka-
lies have been swallowed, dilute alkaline drinks after the deglutition
of acids. Impacted foreign bodies must be removed or, if removal be
impracticable, forced into the stomach. The diet should consist prin-
cipally of bland, mucilaginous liquids, and when the patient is unable
to swallow, nourishment must be given by enema. Thirst may be
assuaged in these cases of aphagia, by sucking juicy acid fruits or
small pieces of ice, or by simply rinsing the mouth with water. After
the acute symptoms have subsided, a bougie should be passed at fre-
quent intervals to prevent the formation of stricture. The principal
remedial agents are Acon., Arnica, Arsenic., Bellad., Canth., Hydropho.,
Kali bichr., Mer. sol., Mezer., Rhus rad., Rhus tox., and Verat. vir. Spasms
of the œsophagus require Bapt., Bell., Coccul., Lach., Phos., etc.* When
the spasm is caused by the impaction of a foreign body, Bell., Cicuta,
or Ignat. will afford relief.
Special Indications.-Aconite.-Violent pain in the middle of the chest, ex-
tending through to the back with a feeling as if the food lodged near the heart-this
pain is aggravated by motion; inability to lie on the back; high fever with thirst,
nervous distress, restlessness, and anxiety. Useful only in the early stages.
Arnica.-Burning in the back of the throat; stinging and darting pains during
deglutition; pains produce delirium. Indicated when the oesophagus has been bruised
by the passage of a foreign body.
Arsenic.-Burning pains, soreness, dryness and constriction in the throat; food
is ejected as soon as it reaches the larynx; pains are felt during sleep and cause shud-
dering and chilliness; cramping pains with feeling of pressure in the oesophagus.
Characteristic anguish, restlessness, and thirst.
Belladonna.-Deglutition difficult or painful; violent spasmodic contraction
of œsophagus and pharynx, causing expulsion of the food; these spasms are renewed
whenever the patient attempts to eat or drink; a feeling as if the parts were too
narrow; sensation as if a foreign body had lodged in the oesophagus; lancinating or
stitching pains when swallowing; flushed face with dilated pupils and throbbing of the
carotids.
Cantharides.-Especially serviceable when the inflammation is due to burns or
scalds of the oesophagus. Dysphagia with violent burning and constriction of the
œsophagus and nocturnal regurgitation; thirst with aversion to all fluids.
Hydrophob.-Burning, stinging pains in the throat; periodical spasms of the
cesophagus; aversion to fluids, especially water; constant desire to swallow; speech
difficult or incorrect; cough and gagging.
Kali bichrom.-Burning from pharynx to stomach; after swallowing solids
there is a sensation as if something remained in the oesophagus; viscid, stringy saliva.
Merc. sol.-Burning and aching pains in the esophagus, associated with painful
pressure and a feeling of dryness, causing a constant desire to swallow. Deglutition
difficult, with danger of suffocation; liquids are ejected through the nose; feeling when
eating as if the food passed over raw spots; fetid breath; ptyalism.
* Vide Treatment of Spasmodic Stricture.
DISEASES OF THE ORGANS OF DIGESTION.
567
Mezereum.-Dysphagia with violent burning and soreness in the upper por-
tion of the œsophagus; aching in the throat when swallowing.
Rhus radicans.-Excessive hot and raw feeling in the throat, with sharp
pain and sensation of hardness, soreness, and contraction when swallowing; dryness
of throat and burning in the esophagus; painful deglutition.
Rhus tox.-Burning and soreness in the oesophagus; throat feels swollen in-
ternally; pricking pain as if a pin had lodged in the throat; feeling of contraction in
the oesophagus; dysphagia with stinging pains during deglutition.
Veratrum viride.-Dryness, heat, and burning in the fauces and oesophagus;
spasms of the oesophagus; rising of frothy, bloody mucus; nausea, vomiting, and
hiccough.
Compare also Asa foet., Carbo veg., Cicuta, Coccul., Euphorb., Hydro-
cyan. acid, Hyos., Kali c., Lach., Lauroc., Natrum mur., Nitric ac.,
Phos., Plumb., Sabad., Secale, and Silicea.
STRICTURE OF THE ESOPHAGUS.
Synonyms. Stenosis of the oesophagus, Contraction of the œso-
phagus.
This term is used to designate a contraction or occlusion of the
œsophagus from any cause, although, according to strict pathology, it
should be limited to those cases in which the diminished calibre of
the tube is the result of structural changes of its walls. Excluding
cases due to spasm, we may divide strictures according to their
origin into three varieties-congenital, organic, and mechanical.
Etiology.-Congenital stricture is caused by lack of development
during ante-natal life, and is exceedingly rare. Organic stricture
usually depends upon cancerous infiltration of the œsophageal walls,
or upon cicatricial contraction following corrosive inflammation,
ulceration, or abscess. It may also be induced by acute or chronic
catarrhal œsophagitis terminating in hypertrophy of the mucous and
submucous tissues with or without fibrinous deposit.
Mechanical stricture is due either to compression of the oesophagus
by aneurisms, retro-oesophageal abscesses, enlarged lymphatics and
tumors of the neck and mediastinum, cancer of the lungs and pleura,
bronchocele, exostosis or caries of the vertebræ, dislocation of the hyoid
bone, etc., or to the protrusion of morbid growths into the canal and
the blocking-up of the passage by masses of the thrush-fungus or by
the impaction of a foreign body. In rare instances the obstruction
may be due to "an abnormal laxity of the mucous membrane per-
mitting a fold to be formed in such a manner as to impede the passage
of the bolus, though there would be little or no impediment to regurgi-
tation and vomiting."t
Anatomical Characters.-The favorite sites of stricture are (1)
opposite or slightly below the cricoid cartilage, (2) near the junction
* Spasmodic strictures will be considered under the head of "Neuroses."
† Cohen, op. cit., p. 291.
568
!
A SYSTEM OF MEDICINE.
of the œsophagus and the pharynx, and (3) at the cardiac extremity ;
but the constriction may occur in any portion of the tube. It is
usually annular, and ranges in depth from a few lines to three or four
inches. It is generally single, but two, three, and even four, strictures.
have been found in the same patient. The diminution in the calibre
of the canal varies from a barely perceptible contraction to complete
occlusion. The morbid process rarely attacks the muscular struc-
tures, but in most instances is confined to the mucous and submucous
tissues, which are unnaturally hard and of a grayish, whitish or
slightly bluish color. When the contraction is slight, the parts in its
immediate vicinity remain normal; but when the occlusion is com-
plete, or nearly so, the œsophagus above the stricture is dilated into
a pouch, whose walls are at first hypertrophied, and later undergo.
fatty degeneration. The irritation caused by the retention of food in
this pouch may induce ulceration or abscess, and ultimately lead to
perforation. Below the constriction the tube is collapsed and, often,
atrophied.
Symptomatology. In the majority of cases the disease develops.
insidiously. For weeks and months the only symptom may be an
occasional difficulty in swallowing large morsels, and this slight im-
pediment is readily overcome by drinking water or by forcible deglu-
tition. The dysphagia slowly increases until the ability to swallow.
solids is lost. The smallest quantity of food, even when finely masti-
cated and reduced to a semi-fluid consistence, is arrested just above
the stricture. In some instances, after repeated and violent deglutory
efforts, aided by external manipulation of the esophagus, the bolus.
passes through the constriction and enters the stomach; more fre-
quently, however, it is regurgitated, covered with mucus, blood or
pus. The act of deglutition often provokes a spasm of the oesophagus,
attended with great nervous distress, a feeling of suffocation, spas-
modic contraction of the chest, palpitation of the heart, and pain be-
hind the sternum, in the stomach, or, more rarely, in the cervical
region.
Finally, the stricture becomes impervious, not only to solids and
semi-solids, but in the worst cases even to liquids. If the upper portion
of the tube be affected, all aliment is ejected as soon as the patient at-
tempts to swallow; when the constriction is near the cardiac extremity,
the bolus is first swallowed and then regurgitated after an interval of
fifteen to thirty minutes; and when there is extensive dilatation above
the stricture, the food may be retained for hours and undergo partial
decomposition before ejection. This rejected matter always has an
alkaline reaction.
The acoustic phenomena detected by auscultation vary according
to the roughness or smoothness of the walls and the degree of con-
traction. The passage of the bolus through a narrow stricture is at-
DISEASES OF THE ORGANS OF DIGESTION.
569
tended with creaking. In some cases choking and gurgling noises.
are heard. In others the normal oesophageal sounds suddenly cease
at the point of constriction, and are followed by those due to the as-
cent of bubbles of air or the regurgitation of the ingesta.
In some cases of organic stricture dysphonia and dyspnoea are in-
duced by paralysis of the recurrent laryngeal nerve.*
As long as sufficient nourishment can be taken to maintain nutri-
tion, the general health is not much impaired; but as soon as there is
serious interference with deglutition, the digestive functions become
seriously disordered, and the patient is troubled with acidity, flatulence,
and constipation. As the disease slowly approaches a fatal termina-
tion, the constitutional symptoms become more pronounced. Ema-
ciation ensues, the abdomen is sunken, the features are sallow, pinched,
and have an anxious, haggard expression; the impoverished blood is
no longer able to maintain the normal heat of the body, and the suf
ferer finally dies of slow starvation. In some cases, the reduced con-
dition of the vital powers gives rise to tuberculosis and gangrene which
precipitate the fatal issue; in others, death occurs from perforation or
rupture of the oesophagus.
Diagnosis. The diagnosis is comparatively easy. The conjunc-
tion of dysphagia, spasm and regurgitation affords strong presump-
tive evidence of stricture, and careful auscultation will enable us to
determine with approximate accuracy the site of the constriction.
The history of the case and laryngoscopic examination furnish data
by which we can decide in the majority of cases whether the stricture
is organic, mechanical, or spasmodic. But no symptom, or group of
symptoms, furnish conclusive proof; this can be obtained only by the
passage of the sound which detects with unfailing accuracy not only
the existence of strictures, but also their character, number, exact
location, diameter, and consistence. It must be used, however, with a
cautious hand, for the exercise of undue force may result in perfora-
tion of the œsophagus.
Prognosis. The prognosis is controlled to some extent by the
cause of the disease, but is generally unfavorable. Congenital strict-
ures are usually, but not invariably, fatal. In mechanical strictures
the prospect of a recovery depends entirely upon the character of the
primary affections. The prognosis is comparatively favorable when
the disease is caused by cicatricial contraction or fibrinous deposit in
the upper portion of the tube, but even these cases sometimes prove
intractable. Strictures due to carcinoma are always inimical to life.
Treatment. When the disease is due to compression or obstruc-
tion of the œsophagus, our first efforts must be directed to the removal
of the cause by appropriate medical or surgical treatment, whenever
such removal is practicable.
* Cohen, op. cit., p. 292.
570
A SYSTEM OF MEDICINE.
The treatment of carcinomatous strictures will be considered under
"Morbid Growths."
For non-malignant organic strictures, Professor Helmuth* recom-
mends Bell., Con., Hyos., Ignat., Lycop., Merc., Natr. mur., Nux v.,
Puls., Sul. ac., and Verat. In vol. ii. of the American Homœopathic Re-
view, Dr. B. F. Joslin, Jr., gives the following remedial indications:
Belladonna.-Sensation as of a lump which cannot be removed. Impeded
deglutition or entire inability to swallow even liquids. Short-lasting but frequently
recurring contraction of the oesophagus. When swallowing, one experiences a sensa-
tion in the throat as though the parts were too narrow, contracted, as if nothing would
go down. Pressure in the throat, with choking ascending from the abdomen.
Ignatia.—Sensation as if one swallowed over a lump. Strangulating sensation
in the middle of the fauces, as if a large lump had lodged in the throat. Difficulty in
swallowing solid or liquid food.
Mercurius.-Sensation as if something had lodged in the throat. Difficult
deglutition. He had to press very hard to get something down. Spasmodic difficulty
in swallowing, with danger of suffocation. Aching pain in the œsophagus.
Natrum mur.-Sensation as though a plug had lodged in the throat. Spasms
in the pharynx. When swallowing, she found it very difficult to get the food down
or bring it up again, so that she came near suffocating.
Pulsatilla.-Sensation on swallowing as if the back part of the throat were
narrower than usual, or closed by swelling. Sensation as if the pharynx were swollen.
When swallowing, he feels as though the throat were swollen. Difficult swallowing, as
if from paralysis of the muscles of deglutition. Choking pain in the pharynx, as if
from swallowing too large a morsel.
But the most carefully selected remedies are comparatively power-
less. They will relieve pain and control spasm; they may even re-
tard for a time the progress of the disease, but in no well-authenticated
instance have they effected a cure.
When the constriction is located in the upper portion of the tube,
favorable results are often obtained by gradual dilatation with bougies
or probangs, preceded in some cases by division of the constriction;
the treatment is necessarily protracted, and failures are not uncom-
In strictures near the cardiac extremity the preference should
be given to electrolysis. The other operations which have been pro-
posed-divulsion, destruction of the cicatricial tissue by caustics,
œsophagotomy and gastrostomy-are rarely successful.
mon.
When the patient is unable to swallow, a small tube should be
passed through the constriction, and liquid food injected into the
stomach; or, if the stricture be impervious, life may be prolonged by
nutrient enemata.
DILATATION OF THE ESOPHAGUS-ESOPHAGOCELE.
Dilatation of the oesophagus may be general or partial. In the
former variety, the whole, or nearly the whole, of the tube is affected;
in the latter, only a limited section is involved. Partial dilatations.
may be subdivided into annular or saccular dilatations and diverticula.
* System of Surgery, p. 699.
DISEASES OF THE ORGANS OF DIGESTION.
571
General Dilatation is usually caused by stenosis of the cardiac orifice
of the stomach, or by muscular paralysis of the tube, induced by
chronic catarrhal inflammation. The enlargement may be very slight,
or it may attain an enormous size. In the remarkable case reported
by Professor Luschka,* the oesophagus measured 30 centimetres in
circumference at the largest part, and 46 centimetres in length. The
walls are usually hypertrophied; the mucous membrane may be nor-
mal, but is more frequently ulcerated, eroded, and studded with poly-
poid growths.
Annular or Saccular Dilatation is occasionally congenital, but is gen-
erally the result of stricture or of the impaction of a foreign body. It
affects only a limited portion of the œsophagus, is largest just above
the obstruction, and gradually diminishes in size from below upward.
In the majority of cases the whole circumference of the affected por-
tion of the tube is equally dilated, but unequal dilatations are not in-
frequent. There is usually hypertrophy of the muscular structures.
Diverticula are generally caused by the impaction of foreign bodies
and the retention of food above them; as the result of pressure thus
exerted upon a circumscribed portion of the posterior wall, the mus-
cular fibres separate, and the mucous membrane protrudes between
them; with every deglutory effort this protrusion is increased; and
finally a funnel-shaped pouch is formed which lies between the œsoph-
agus and the vertebrae. They may also be produced, as Rokitansky
has shown, by inflammation of the bronchial gland near the bifurca-
tion of the trachea. During the inflammatory stage these glands con-
tract adhesions to the external wall of the esophagus, and, as they
subside to their normal volume or undergo cicatricial contraction,
draw out the portion of the tube to which they are attached. Occa-
sionally they are due to ruptures of the muscular coat by blows or
falls, and in some instances the cause is unknown.
Diverticula, caused by the impaction of foreign bodies, are usually
single. They are always located just below the inferior constrictor
muscle of the pharynx, and are frequently associated with pharyn-
gocele. Those due to the shrinkage of diseased bronchial glands are
often multiple. When the diverticulum is small, and communicates
with the œsophagus by a narrow, fissure-like opening, it offers no se-
rious impediment to deglutition. On the other hand, when it is large.
and has a patulous, elliptical, or circular orifice, it often drags the
œsophagus out of position, usurps its place, and forms a blind pouch,
which not only intercepts the passage of food to the stomach, but by
its pressure upon the lower portion of the tube, produces mechanical
stricture. The irritation, induced by this retention of food in the di-
verticulum, leads to inflammation, ulceration, and perforation into the
mediastinum, bronchi, lungs, or pleura.
* Virchow's Archiv für Anat., March, 1868.
572
A SYSTEM OF MEDICINE.
Symptomatology.-General dilatation, when slight, presents no
characteristic symptoms. When the enlargement is moderate, and the
muscles retain their contractility, there is little or no difficulty in
swallowing; but as soon as the walls become paralyzed by overdis-
tension, dysphagia occurs, and may increase to complete aphagia. In
some instances there is rumination, and Cohen* reports a case in
which the patient "confessed to a sensual pleasure in the process."
The sound passed down the œsophagus encounters no obstruction, but
can be freely moved in all directions. Auscultation shows diminished
vigor of peristaltic action; the bolus is no longer gradually transmitted
downward, but seems to drop at once into the stomach.
In annular dilatation, the symptoms are similar to those of stricture,
but food is retained longer and in larger quantities. When the upper
part of the œsophagus is the seat of the dilatation, a unilateral or bi-
lateral swelling appears behind the trachea immediately after eating,
and completely disappears after regurgitation or vomiting. In some
instances, pressure upon this sac expels its contents with a splashing
or gurgling sound. When the dilatation is large, it may seriously
interfere with respiration, circulation, and innervation by its pressure
upon the trachea, blood vessels and nerves. When the food is finally
expelled by regurgitation or emesis, it is undigested, mixed with mu-
cus, partially decomposed, has an alkaline reaction and a sweetish,
insipid, or foul taste. The breath is usually horribly offensive. The
exact site of the dilatation can be ascertained by a cautious use of
the sound, and auscultation reveals "a general sprinkling of the fluid.
bolus not unlike that of rain deflected by the wind."†
Diverticula of moderate size often cause no symptoms at all. When
they are large enough to interfere with the passage of food, they give
rise to phenomena similar to those above described; but regurgitation.
does not occur until several hours after a meal, and there is greater
decomposition of the ingesta. As the size of the pouch increases the
dysphagia gradually diminishes. In some instances, as already noted,
the diverticulum displaces the oesophagus and forms a cul-de-sac
which receives the food. If an attempt be made to pass the sound
soon after eating, the point of the instrument enters this sac and is
arrested; a few hours later, when the pouch has been emptied by re-
gurgitation or vomiting, the sound readily passes the obstruction and
enters the stomach. This variation in results at different times is con-
clusive evidence of the existence of a diverticulum.
In any form of dilatation, whenever the amount of food which
reaches the stomach is insufficient to maintain the vital processes, we
have symptoms of inanition. The features become haggard and
pinched, gradual loss of flesh and strength ensues. The extremities
are habitually cold, there is undue susceptibility to atmospheric
* Op. cit., p. 301.
† Cohen, op. cit., p. 301.
DISEASES OF THE ORGANS OF DIGESTION.
573
changes, and finally the patient either perishes of starvation, or death
occurs from perforation of the œsophagus, followed by gangrenous in-
flammation of the intra-thoracic viscera.
Diagnosis. The diagnosis is based upon the symptoms above enu-
merated, and especially upon the results obtained by exploration with
the sound. When the dilatation affects the upper part of the œsopha-
gus, the swelling behind the trachea may be mistaken for an abscess
or tumor, but can readily be distinguished by its increase in size after
eating, and its subsidence after regurgitation or vomiting.
Prognosis. The prognosis is always grave. The majority of pa-
tients ultimately perish, though the suffering may be prolonged for
years.
Treatment.-Foreign bodies should be removed and strictures
dilated, if possible, when the disease depends upon these causes. In
general dilatation due to paralysis, Caust., Coccul., Cupr., Gelsem., Lach.,
etc., may prove useful. To prevent the retention of food in diver-
ticula, liquid nourishment must be given through a stomach-tube.
*
PERFORATION AND RUPTURE OF THE ESOPHAGUS.
Perforation of the oesophagus may occur from within outward, or in
the reverse direction. Perforation from within is due to the impaction
of foreign bodies, abscess, ulceration and carcinoma; peforation from
without is due to pressure upon the tube caused by aneurisms of the
aorta, tubercular degeneration of the bronchial glands near the bifur-
cation of the trachea, caries of the vertebræ, retro-oesophageal abscess,
tubercular cavities in the lungs, etc. The perforation usually occurs in
the thoracic portions, and may be single or multiple.
Rupture of the healthy oesophagus is exceedingly rare. In the
majority of cases, solution of continuity occurs only when the walls.
have been previously weakened by cancerous degeneration, ulceration,
or atrophy, and is then induced by severe retching or vomiting. The
rupture is usually longitudinal, more rarely transverse; its most fre-
quent site is just above the diaphragm.
Unless the opening is very small, perforation and rupture of the
œsophagus are followed by the escape of its contents into the sur-
rounding areolar tissue, or into the trachea, pericardium, lung or pleu-
ral sac. Mucus, pus, blood, and the products of tubercular degenera-
tion may also pass into the oesophagus and be expelled by vomiting.
Symptomatology.-The symptoms are sudden, intense, deep-
seated pain in the breast, with a sensation as if something had given
way in the oesophagus, followed by nausea, vomiting, cough, emphy-
sema of the neck, paroxysms of suffocation, orthopnoea, slight cyano-
sis, chills, coldness of the extremities, cold sweat, pallor, fainting, and
* Vide Treatment of Paralysis of the Esophagus.
574
A SYSTEM OF MEDICINE.
collapse. If the patient survive the immediate effects of the injury,
these symptoms are succeeded by those of purulent or gangrenous in-
flammation of the mediastinum, lungs, pleura, or pericardium.
Diagnosis. When these phenomena occur in a person who is
known to have chronic disease of the oesophagus or of the intra-tho-
racic viscera, there need be no doubt about the diagnosis.
Prognosis. The prognosis, although dependent to some extent
upon the cause and the site and extent of the injury, is generally un-
favorable. If the opening be so small that there is no escape of the
contents of the tube, or if there be a single slight discharge, followed
by a circumscribed peri-oesophageal abscess, which "bursts externally,
leaving a fistula, or internally into the oesophagus," recovery may be
expected. But unfortunately, these cases are extremely rare; and
when they do occur, the absence of the characteristic symptoms of
perforation and rupture renders the diagnosis uncertain. In the ma-
jority of instances, death either occurs instantaneously from shock or
hæmorrhage, or within a few days from the secondary lesion of the
neighboring structures; but occasionally the sufferings are prolonged
for weeks and months.
Treatment. The most essential part of the treatment is absolute
avoidance of swallowing and perfect rest in the recumbent position.
All nutrition must be given by enema, for the use of the stomach-tube
is hazardous. Thirst may be allayed by rinsing the mouth with sim-
ple or acidulated water, by allowing small pieces of ice to slowly melt.
upon the tongue, or by occasionally sponging the body. For the
symptoms accompanying, or immediately following, the injury, Camph.,
Verat., Arsen. or China may be administered, either hypodermically
or by the rectum. When the primary lesion is succeeded by gangre-
nous inflammation of the adjacent structures, Arsen., Crotal., Kreos.,
Lach., Secal., etc., may be tried; but in these cases the result is inevita-
bly fatal. In those rare instances in which the only secondary lesion
is a small peri-œsophageal abscess, Hep., Merc. or Silic. will be indi-
cated; after its contents have been discharged, and sufficient time has
elapsed for firm cicatrization, we may cautiously return to nutrition
by the mouth.
MORBID GROWTHS OF THE ESOPHAGUS.
The œsophagus may be the seat of both benign and malignant
morbid growths. The former are comparatively rare; fibroid polypi
constitute the most frequent and, clinically, the most important variety;
lipoma, papilloma, myoma, and myxoma may also occur. Carcinoma,
on the other hand, is the most common and the most fatal disease of
the œsophagus. It may be scirrhous, medullary or epithelial. The
DISEASES OF THE ORGANS OF DIGESTION.
575
majority of surgical writers, including Gross* and Helmuth,† agree
that scirrhus is the most frequent variety; Cohen, however, claims
that in order of frequency, medullary is entitled to the first place, epi-
thelial to the second, and scirrhous to the third; while Ziemssen§
asserts with equal positiveness that primary cancer of the tube is always
epithelial.
Etiology. The etiology of morbid growths is unknown. Carci-
noma rarely occurs before middle life, and attacks men more fre-
quently than women. In some cases local injury by mechanical,
chemical, or thermal irritants has seemed to act as an exciting cause.
Anatomical Characters.-Benign growths may occur in any
portion of the œsophagus. They usually originate in the submucous
tissue, and may be either pedunculated or sessile. Occasionally they
are attached by long, slender pedicles to the posterior nares, the pha-
ryngeal surface of the epiglottis and larynx, or the posterior wall of the
pharynx, and merely hang into the tube. They grow slowly, and
sometimes attain the dimensions of an ordinary sausage.
Carcinoma is usually primary; more rarely it is secondary to cancer
of the tongue, larynx, epiglottis, or stomach. It occurs most fre-
quently either at the upper or lower extremity; occasionally it attacks
only the central portion; and exceptionally it may involve the entire
length of the oesophagus. The morbid process affects the whole cir-
cumference of the tube, and produces stricture; above the constriction
the walls are hypertrophied and dilated; below it they are usually
collapsed and atrophied. The disease begins in the submucous tissue,
either in the nodular or diffuse form, and soon extends to the mucous
membrane. The cancerous growth protrudes into the canal, disinte-
grates and sloughs, leaving large, irregular ulcers covered with vascu-
lar, fungoid granulations, or shreds of gangrenous tissue. From the
œsophagus it spreads to the adjacent intra-thoracic viscera ; metastatic
deposits occur in the liver, lungs, kidneys or brain; and finally there
is perforation into the larynx, trachea, mediastinum, lungs, pleura,
pericardium, aorta, pulmonary, carotid, or subclavian artery.
Symptomatology.-Benign tumors, when small, cause no incon-
venience, and are rarely detected during life; large tumors produce.
symptoms similar to those of stricture. As a rule, these growths are
painless.
Carcinoma develops insidiously. At first, there may be merely a
gradual loss of flesh and strength, associated with a vague feeling of
uneasiness in the oesophagus. As the disease progresses, dysphagia
appears, and gradually increases to complete aphagia; the food is re-
gurgitated, mixed with mucus, blood, or fragments of disintegrated
cancerous tissue, and the patient is tormented with severe pricking,
* System of Surgery, vol. ii., p. 500.
‡ Op. cit., p. 303.
† System of Surgery, p. 699.
? Ziemssen's Cyclopædia, vol. viii., p. 173.
576
A SYSTEM OF MEDICINE.
burning, or lancinating pains, which often extend downward to the
stomach, producing gastralgia and cardiac spasm, or backward to the
spine between the scapulæ, or they dart upward to the neck and head,
and radiate to the shoulders and arms. Dysphonia and aphonia may
be produced by compression of the recurrent laryngeal nerve, and
pressure upon the larynx and trachea may give rise to dyspnoea. As-
sociated with these local phenomena, there is a well-marked cancerous
cachexia, characterized by a peculiar sallow, dirty-yellow, cadaverous
complexion, and rapid emaciation. Death ultimately ensues from
marasmus, from perforation of the esophagus, or, in some cases, from
hæmorrhage. More rarely, the fatal result is due to secondary inflam-
mation of the brain or lungs, caused by metastatic cancerous deposits
or to paraplegia, induced by extension of the disease to the spinal
cord.* The duration of carcinoma is from one to two years.
Diagnosis.-Benign growths arising outside the oesophagus, or sit-
uated in the upper portion of the tube, can readily be detected by
direct inspection or by laryngoscopic examination, while exploration
with the sound will detect those located near the cardiac extremity.
Carcinoma may always be suspected when symptoms of organic stric-
ture are associated with burning, lancinating pains and well-marked
cachexia in a patient of advanced years; and this suspicion may be
converted into a certainty by microscopical examination of the can-
cerous fragments regurgitated with the food.
Prognosis. Benign growths, even when they have attained con-
siderable bulk, are seldom dangerous. A large pedunculated tumor,
suddenly ejected into the mouth or pharynx during emesis, may ob-
struct the entrance to the larynx and cause suffocation, and a few in-
stances have been recorded in which large fibroid polypi produced
complete obstruction of the tube and subsequent death by inanition;
but these cases are extremely rare.
In carcinoma the prognosis is hopeless.
Treatment.-Benign growths, when readily accessible, may be re-
moved by the ligature, écraseur, or galvano-cautery; when they are
located at some distance within the tube, these operations must be pre-
ceded by œsophagotomy.
cancer.
As Lilienthal tersely expresses it, "there are no remedies yet for
The individuality of the patient and the concomitant symp-
toms may aid us in selecting the remedy, which, for the time being,
will alleviate the suffering "-and this is all that we can hope to ac-
complish. The medicines most frequently serviceable are Apis, Ar-
sen., Carbo, Galium aperine, Kreos., Lach., and Phytol.
In the early stages, if the patient is unable to swallow, nourish-
ment must be given through the stomach-tube, or if the stricture be
impervious, by enema. After ulceration has ensued, the weakened
* Ziemssen, loc. cit.
† Homœopathic Therapeutics.
DISEASES OF THE ORGANS OF DIGESTION.
577
walls are easily perforated, and, although the calibre of the tube is
partially restored, the use of the tube is dangerous, and we must rely
exclusively upon rectal alimentation.
NEUROSES OF THE ESOPHAGUS.
Very little is known in regard to the derangements of the sensory
nerves of the œsophagus. Anæsthesia, hyperæsthesia, and neuralgia
occasionally occur, but their ætiology is obscure, and their diagnosis
difficult.
The motor disturbances-spasmodic stricture and paralysis-have
been more thoroughly investigated.
SPASMODIC STRICTURE OF THE ESOPHAGUS.
Synonyms. Spasm of the oesophagus, Esophagismus, Dyspha-
gia spasmodica, Esophagospasmus, Cramp of the oesophagus.
This very singular disease, as Gross justly styles it, attacks both
sexes and may occur at any period of life from infancy to old age, but
is most common in nervous, excitable women, soon after puberty or
at the menopause. Its most frequent cause is, undoubtedly, local irri-
tation due to inflammation or ulceration of the lining membrane of
the tube, the presence of morbid growths and foreign bodies, either in
the pharynx or the esophagus, or to external pressure upon the
œsophageal walls, occasioned by cervical spondylitis, retro-pharyngeal
abscess, bronchocele, enlarged lymphatic glands, tumors of the pos-
terior mediastinum, and aneurisms of the aorta, carotid, or innominate
artery.
It may also occur as the result of irritation or actual disease of the
brain, spinal cord, and pneumogastric nerve, or depending upon gout,
rheumatism, tetanus, hydrophobia, and hysteria.
In some instances, the spasm is induced by irritation of the periphe-
ral branches of the pneumogastric external to the esophagus. Under
this head may be included diseases of the larynx, functional or or-
ganic affections of the stomach, especially carcinoma, intestinal irrita-
tion due to worms, and uterine irritability dependent upon pregnancy,
metritis, flexions, or morbid growths. In vol. ii. of the American Hom-
œopathic Review, Dr. B. F. Joslin, Jr., gives the details of a singular
case which terminated fatally. At the autopsy, an osseous growth
"about an inch long and half an inch in breadth and thickness, with nu-
merous spicule of bone projecting from it," was found loosely attached
to the trachea, just above its bifurcation, and "closely adherent to the
vena cava superior." Intimately attached to its anterior surface was
a nerve-filament which was believed to be the cardiac branch of the
VOL. I.—37
*
System of Surgery, vol. ii., p. 498.
578
A SYSTEM OF MEDICINE.
vagus. This tumor, Dr. Joslin states, exerted no pressure upon the
œsophagus, and could, therefore, only be implicated in the production
of the symptoms by its relation with the pneumogastric nerve.
Again, in a certain proportion of cases, the spasms may be induced.
by irritation or disease of remote parts which have no direct nervous
connection with the oesophagus. A striking illustration of this fact
will be found in the instance cited by Gross, in which the whole train
of morbid phenomena promptly disappeared after the removal of hæm-
orrhoidal tumors.
*
Finally, in many cases, the origin of the disease is undoubtedly
psychical. Anger, fright, or the fear of hydrophobia, are sufficient to
bring on an attack; while in persons subject to these paroxysms, the
dread of their recurrence, or merely the thought of swallowing, may
induce the spasm.
According to their ætiology, spasmodic strictures of the oesophagus
are divided into symptomatic and idiopathic, the latter including all
those for which no definite anatomical cause can be assigned.
Symptomatology.-The characteristic symptoms are sudden at-
tacks of dysphagia, sometimes painless, but more frequently associated
with a sensation of burning and constriction in the chest, severe pain.
in the pharynx and oesophagus, or in the oesophagus alone, globus.
hystericus, hiccough, embarrassed respiration, great mental distress,
with fear of impending suffocation, and, in severe cases, violent mus-
cular spasms of the pharynx, larynx, and chest, and even syncope.
The relaxation of the constriction is often followed by a copious dis-
charge of flatus and limpid urine. The spasm may affect any portion.
of the esophagus, and in some persons its apparent site varies with
each attack. If the upper portion of the tube be affected, food and
drink are ejected as soon as the patient attempts to swallow. When
the constriction is at, or near, the cardiac extremity, the bolus is first
swallowed and then regurgitated, mixed with mucus and gas; and in
chronic cases, when the lower portion of the oesophagus is habitually
the seat of spasm, the tube becomes dilated above the constriction, ast
in organic stricture, and the food is retained for several hours, or even
a whole day, before regurgitation. In the majority of instances, how-
ever, deglutition, although difficult, is not impossible, and after re-
peated violent efforts and copious eructations the food finally passes
into the stomach. Liquids are usually swallowed more easily than
solids, but in rare cases the reverse is true. Some patients swallow
warm fluids best, others cold fluids. By careful auscultation in the
dorsal region, sounds due to bubbles of air rising in the oesophagus,
or in other cases those caused by regurgitation of the ingesta, can be
distinctly heard. A sound passed gently down the tube is arrested at
the stricture, but if the point be firmly pressed against the constricted
* Loc. cit.
DISEASES OF THE ORGANS OF DIGESTION.
579
portion for a short time, the obstruction disappears either suddenly
or gradually, and the instrument enters the stomach. It is not always
possible, however, to thus positively demonstrate the existence of spas-
modic stricture, for many cases are recorded in which the introduction
of the sound merely into the pharynx promptly dispelled the spasm.
The duration of a single paroxysm is usually brief, rarely lasting
more than a few minutes, but in exceptional cases it may continue for
hours and even days. The spasms generally recur at irregular inter-
vals; in some instances, however, they are characterized by a marked
periodicity.
The disease, with occasional exacerbations and remissions, or even
with long periods of complete quiescence, may extend over many years,
and Aird has reported a case in which it persisted" during the whole
course of a long life." Usually, however, and especially under proper
treatment, recovery takes place in a few weeks or a few months, pro-
vided the spasm does not depend upon some incurable organic lesion.
As a rule there is no emaciation.
Under the name of "Stenosis spastica fixa continua," Hamburger has
described a rare form of this affection in which a painless, spasmodic
contraction persists for weeks and months, with "fluctuations of
intensity without, at any time, complete disappearance of the
spasm." In consequence of this long-continued interference with deg-
lutition, nutrition is impaired, and the health of the patient seriously
affected.
Post-mortem examinations have thus far yielded only negative re-
sults.
Diagnosis. An accurate diagnosis, especially in the early stages,
is often exceedingly difficult; and no positive opinion should be ex-
pressed until long-continued observation has enabled the physician
to exclude all possible sources of error. No reliance can be placed
upon the suddenness of the attack, since the published cases of Drs.
Thornton and Moorehead † show that this sudden dysphagia may be
the first appreciable symptom of cancer of the oesophagus. The most.
reliable diagnostic tests are the intermittent paroxysms and the
prompt disappearance of the spasm after the introduction of the sound
or galvanization of the pneumogastric. These will usually be sufficient
to distinguish spasmodic stricture from stenosis, dilatation, paralytic
dysphagia, morbid growths, or the impaction of foreign bodies. Even
in the "Stenosis spastica fixa continua" of Hamberger, there are occa-
sional brief intervals in which the power of deglutition is almost wholly
regained.
Prognosis. Spasmodic stricture of the oesophagus is rarely a
dangerous disease per se. Of the idiopathic form, only two fatal cases
have thus far been reported-one published by Dr. Powers in the
* Ziemssen's Encyclopædia, vol. viii., p. 206.
† Vide Lancet, 1881.
580
A SYSTEM OF MEDICINE.
Lancet, for 1866, and that of Dr. Joslin already quoted; and in the
former, the recorded symptoms would seem to justify the conclusion
of Ziemssen* that the patient died of bulbar paralysis rather than
idiopathic spasm of the œsophagus. As a rule, these cases are curable,
but all predictions in regard to their probable duration must be very
guarded.
In the symptomatic variety the prognosis depends entirely upon the
nature and curability of the primary lesion.
Treatment.—The principal remedies for spasmodic stricture are
Alumina, Argent. nit., Arsenic, Asa fœt., Bapt., Bell., Bryon., Canth.,
Carbo veg., Cicuta, Coccul., Elaps, Hydroc. ac., Hydroph., Hyos., Ignat.,
Kali bich., Kali c., Lach., Lycop., Naja, Natr. m., Nitric ac., Phos.,
Plumb., Rhus tox., Stram., and Verat. vir.†
Of these, Alumina, BELL., Canth., Carbo veg., Cicuta, Hyos., Ignat.,
LACH., LYCOP., and Stram. correspond to spasms of the upper portion,
while ARGENT. NIT., Arsenic, Lach., and PHOS. are applicable when the
cardiac extremity is affected. Spasmodic stricture due to œsophagitis
calls for ARSENIC, Rhus tox., and Verat. vir. Asa fœt., Coccul., Ignat. and
Lach. are useful "in nervous, hysterical persons where there is also
reversed peristalsis." Dr. Joslin recommends Bell., Ignat., Merc. sol.,
Natr. m., and Puls.§
+
Baptisia, Belladonna and Phosphorus have the best clinical record.
Special Indications.-Alumina.-Sensation of constriction in the esophagus
when swallowing food; violent, pressive pains as if a portion of the oesophagus were
contracted or compressed in the middle of the chest, especially during deglutition, but
also when not swallowing, with oppression of the chest alternating with palpitation of
the heart, especially after a meal. Great dryness of all the mucous membranes.
Argent. nit.-Paroxysms of cramp in the oesophagus; the oesophagus feels spas-
modically closed, producing a sensation in the stomach as if it would burst.
Arsenic.-Violent burning pains, soreness and sensation of constriction in the
œsophagus; deglutition difficult, painful or impossible; food either lodges in the so-
phagus, producing a feeling of pressure, or is ejected as soon as it reaches the pharynx;
dryness and burning in the throat; characteristic thirst and mental symptoms.
Asa fœtida.- Food, when partially swallowed, returns into the month; spasms of
the oesophagus with reversed peristalsis; aching and burning in the oesophagus; mental
and physical hypersensitiveness; nervous, hysterical persons.
Baptisia.-ŒEsophagus feels constricted from the pharynx to the stomach; can
swallow liquids only; aversion to the open air. (This inability to swallow solids is also found
under Natr. m., Nitric ac. and Plumb., but is considered by Professor H. N. Guernsey
to be especially characteristic of Bapt.).
Belladonna.-Violent spasmodic contractions of the esophagus causing the
food to be expelled; extremely difficult and painful deglutition, with sensation as if the
parts were too narrow; constant desire to swallow, but every attempt at deglutition
renews the spasms of the pharynx and oesophagus; face flushed, pupils dilated (Bell.,
Cicuta, and Ignatia are especially useful when the spasmodic contractions are due to the
presence of a foreign body).
Bryonia.-Pressive, sticking pains and painful sensation of contraction in the
œsophagus, especially in the lower portion, with inability to swallow.
* Loc. cit.
† Vide Studies in Mat. Med., 'by Professor E. A. Farrington, Hahn. Monthly, vol. 15.
Hahn. Monthly, loc. cit.
2 Amer. Hom. Review, vol. ii.
DISEASES OF THE ORGANS OF DIGESTION.
581
Cantharides.-Burning and constriction of the oesophagus; deglutition difficult,
painful or impossible; nocturnal regurgitation; thirst, with aversion to all fluids.
Carbo veg.—Painless spasmodic contractions of the pharynx and œsophagus;
dysphagia; feeling of coldness in the throat.
Cicuta.--Spasmodic closure of the oesophagus, with danger of suffocation after
swallowing a sharp piece of bone; deglutition impossible; the throat seems grown
together internally, and is painful externally; frequent eructations.
Cocculus.-Choking constriction of the oesophagus causing dyspnea and cough;
dryness of the pharynx and oesophagus; burning pain in the oesophagus, pharynx and
fauces, with taste of sulphur in the mouth; desire for acids or thirst, with aversion to
drink; hysterical person.
Elaps. Constriction of pharynx and oesophagus; food and liquids are suddenly
arrested, and then fall heavily into the stomach. (Spasm followed by paresis.)
Hydrocyanic acid.-Spasms in pharynx and oesophagus, with heat, inflam-
mation and inability to swallow.
Hydrophobinum.-Spasms of the oesophagus returning periodically; constant
ineffectual urging to swallow; aversion to all fluids, especially water; burning, sting-
ing pains in the throat; speech difficult or incorrect.
Hyoscyamus.-Spasmodic contractions interfering with speech and respira-
tion; aggravation from cold fluids; solids and warm drinks are swallowed most easily;
hiccough, nausea, spasmodic cough and stiffness of the cervical muscles.
Ignatia.-Sensation of a lump in the throat; difficulty in swallowing solids or
liquids; hysterical patients.
Kali bichr.-Burning sensation from pharynx to stomach; pain and sensation as
if something remained in the oesophagus after swallowing solids.
Kali carb.—Food lodges in the oesophagus and produces gagging and vomiting;
dysphagia with great sensitiveness of the oesophagus, which is aggravated by warm
food or drink; can take only lukewarm nourishment.
Lachesis.—Sensation as if a button or crumb had lodged in the throat; gagging
and smothering when attempting to swallow, as if the food had gone the wrong way;
can swallow solids more easily than liquids; the spasms rouse him from sleep or develop as
he awakes; intolerance of all pressure about the neck and throat.
Laurocerasus.-Spasmodic contraction of the throat and oesophagus, with
impeded deglutition; dull pain in the throat extending to the right scapula; burning
pain in throat, with accumulation of tenacious mucus.
Merc. sol.-Difficult deglutition with danger of suffocation; liquids are ejected
through the nose; pressure, burning and aching pains in the esophagus.
Naja.-Deglutition greatly impeded, hardly anything can pass into the stomach.
Natrum mur.-Spasms of the pharynx; can swallow only liquids; solids, when
they reach a certain point, are violently ejected with gagging and attacks of suffocation.
Nitric acid.-Violent pains during deglutition; can swallow only liquids; while
eating, small pieces of food are forced into the choanæ.
Phosphorus.-Dryness and burning in the pharynx and esophagus with diffi-
cult deglutition; food scarcely swallowed comes up again.
Plumbum.—Violent spasmodic constriction of the esophagus; liquids can be
swallowed easily, but food comes back into the mouth; burning in the esophagus and
stomach.
Pulsatilla.-Choking pain in the pharynx as if from swallowing too large a
morsel; sensation as if the pharynx was swollen; difficult deglutition.
Rhus tox.-Solids can only be swallowed with difficulty, owing to a feeling of
contraction in the esophagus; burning and soreness in the œsophagus.
Stramonium.-Violent constriction of the throat; deglutition difficult, almost
impossible; terrible spasms of the throat when attempting to swallow.
Veratrum viride.-Spasms of the esophagus with or without rising of frothy,
bloody mucus; constant inclination to swallow; dryness and heat in the throat; burn-
ing in the fauces and œsophagus; constant, distressing hiccough; nausea and vomiting.
The prompt relief obtained by the passage of a sound or by its
introduction merely into the pharynx, has already been mentioned.
582
A SYSTEM OF MEDICINE.
Usually this treatment is only palliative, but in some instances it
effects a permanent cure. Great caution must be observed in the per-
formance of this apparently trivial operation, for if the walls of the
œsophagus are weakened by inflammation or ulceration, the instrument
in unskillful hands may produce perforation or rupture; and when the
calibre of the canal is narrowed by the pressure of an overlying aneu-
rism, the end of the sound may penetrate the aneurismal sac and cause
instant death from hæmorrhage.
Electricity has been successfully employed in obstinate cases. It
may be applied indirectly through galvanization of the pneumogastric,
or directly by means of an insulated œsophageal electrode passed down
to the constricted part and connected with the positive pole of a gal-
vanic or faradic battery, preferably the latter.
The diet should consist principally of nutritious liquids; and in
case of long-continued spasm, associated with marked impairment of
nutrition, the patient must be fed through an œsophageal tube.
PARALYSIS OF THE ESOPHAGUS.
Synonyms. Paralysis oesophagi, Dysphagia paralytica.
Paralysis of the esophagus rarely occurs as an isolated affection,
but is generally associated with paralysis of the tongue, palate, epi-
glottis, pharynx or larynx, or with general paralysis. It may be partial
or complete.
ex-
It is often dependent upon disease of the brain and spinal cord, and
may also be induced by diphtheria, syphilis, alcoholism and chronic
lead-poisoning. In some cases it is due to muscular atrophy of the
œsophageal walls caused by dilatation. It may also result from
ternal adhesions of the œsophagus to intra-thoracic tumors,"* or from
pressure upon the tube by exostoses, abscesses, morbid growths, etc.
More rarely it depends upon mental shock or sudden suppression of
perspiration.
Symptomatology.-The onset of the disease may be sudden or
gradual. When the paralysis is partial it causes no inconvenience.
In the majority of cases, however, there is well-marked dysphagia.
The bolus lodges in the oesophagus, and can only be forced into the
stomach by repeated deglutory efforts, by drinking large quantities of
water, or by taking additional solids. In advanced cases the food
may remain in the canal for hours and, by its pressure upon the intra-
thoracic viscera, give rise to palpitation of the heart and moderate
dyspnoea. Large morsels are swallowed more easily than small ones,
and solids more readily than fluids; the passage of the latter is attended
with a loud rumbling sound. Deglutition is less difficult in the erect
* Cohen, op. cit., p. 326.
DISEASES OF THE ORGANS OF DIGESTION.
583
than in the recumbent position. Regurgitation is present in some
cases, absent in others. As a rule, there is little or no pain. On ac-
count of the difficulty in swallowing, there is constant dribbling of
saliva. In some cases there is rapid emaciation.
A sound passed down the oesophagus encounters no obstruction, and
can be freely moved from side to side. The auscultatory phenomena
are similar to those of dilatation.
Diagnosis. This disease can readily be distinguished from spas-
modic stricture by the evidence afforded by the passage of the sound,
and from paralysis of the pharynx by the ability to swallow the bolus.
A careful distinction between paralysis and dilatation of the œsophagus
is far more difficult; and when the disease develops slowly, and there
is no coincident paralysis of the pharynx or larynx, an accurate dif-
ferential diagnosis between these two affections is often impossible.
Prognosis. This depends entirely upon the cause of the disease.
It is favorable when the paralysis is limited to the oesophagus and is
due to a curable affection. It is decidedly unfavorable when the local
trouble is associated with other paralyses dependent upon lesions of
the brain and spinal cord.
Treatment.—According to Professor Lilienthal,* the principal
remedies are Caust., Coccul., Cupr., Gelsem., Lach., and Silic. Compare
also Arsen., Baryta c., Mur. ac., Nux mos., Nux v., Op., Phos., Plumb.,
and Verat. Electricity has proved beneficial in some cases, in others it
has seemed to aggravate the paralysis. When the food lodges in the
canal, it must be forced downward by the œsophageal sound. In ad-
vanced cases nourishment must be given through the stomach-tube
or by enema.
C. DISEASES OF THE STOMACH.
BY H. R. ARNDT, M.D.
INTRODUCTORY REMARKS TO THE CHAPTER ON DISEASES OF THE
STOMACH.
In entering upon a study of the diseases of the stomach, it seems
necessary to call attention, in a very general way, to certain facts,
which are rather intimately connected with the subject, and refer
exclusively to functional disorders of the organ. These facts are
presented in a decidedly fragmentary manner in order to economize
space, and the remarks made are chiefly intended to serve the purpose
for which so often extensive foot-notes are appended to the body of a
work. Several topics which might properly be discussed here are of
sufficient importance to warrant more extensive treatment than could
* Homœopathic Therapeutics.
584
A SYSTEM OF MEDICINE.
have been afforded them in this place, and consequently have here
received mere mention, but are considered in full under separate
headings.
The process of digestion constitutes one of the most interesting and
important functions performed within the animal economy, and a very
large share of this work, i. e., the changes of the nitrogenous elements
of food which are necessary to fit them for absorption, is performed
within and by the stomach. Whenever the process of digestion is
disturbed or arrested by functional derangement, which may be of
local or of reflex origin, or by some structural lesion, indigestion
results. Our remarks and studies are necessarily confined to what
might properly be called "gastric indigestion."
Indigestion, depending upon a great variety of causes, and giving
rise to a great multitude of symptoms, must not be looked upon as a
pathological entity, but as a symptom of frequent occurrence and of
much practical importance.
Among the causes of indigestion three distinct factors deserve con-
sideration: 1st, the food eaten, its quality and quantity; 2d, disturb-
ances of the mechanism of digestion; 3d, partial or complete failure.
in the chemical changes which constitute an important part of
digestion.
Food. To insure normal and complete digestion, the food taken
must be of proper quality and must be had in proper quantity. The
human organism, for the maintenance of vigorous health, demands a
certain variety of nutritious elements, representing both the animal
and the vegetable kingdom; or, perhaps more correctly, nitrogenous
principles, non-nitrogenous principles, and inorganic matter, as water
and salts, which are best and easiest supplied by a mixed animal and
vegetable diet. The relative proportion of these different elements, to
answer the demands of each individual case, must of necessity differ
with the calling in life, with the nature of the employment and labors
which the calling of the respective individual entails, with age, sex,
temperament, and idiosyncrasy; within certain limits, each person is
a law unto himself, and the natural preference for certain articles of
diet in different persons, in a state of health, is a safe guide in the
selection of the food which readiest supplies the food-elements condu-
cive to the support of life and health. A consideration of the quality
of food best calculated to insure health would lead to an exhaustive
and, probably, impracticable discussion on the subject of diet; in a
general way, it may be stated that Moleschott estimates that a daily
supply of about twenty-three ounces of dry solid matter, one-fifth of
this amount being nitrogenous elements, is well calculated to maintain
"health in a person of average stature under exposure to a temperate
climate and a moderate amount of muscular work;" to this must be
added a daily supply of water varying from fifty to eighty ounces.
DISEASES OF THE ORGANS OF DIGESTION.
585
Experience and common sense suggest general rules of diet which
should always be observed. A person engaged in active and hard
exercise in the open air requires a somewhat stimulating diet, and
may with safety partake far more freely of animal food than a person
of sedentary habits of life. Age and climate also bear directly upon
the subject of diet; a free supply of food the quality of which is well
calculated to insure the physical welfare of a young child would be
utterly insufficient to provide an adult with the strength and endur-
ance necessary to undergo the exertions and the toil which mature
years bring with them; the light diet which, in the tropics, is indis-
pensable to the maintenance of health could by no means take the
place of the liberal amounts of fatty substances which inhabitants
of the frigid zone find so necessary to their very existence; and vice
versa.
To maintain and preserve health, it is not only important to insure.
a fair representation of the various alimentary principles, but care
must be had that no substances are eaten which are unfit for digestion
on account of inherent unfitness, such as noxious and indigestible
substances, or which have been disqualified for food-purposes on
account of partial decay or of improper preparation or cooking. It is
even necessary that a certain proportion of food be taken in the fresh
state, the scorbutic affections illustrating the harm likely to result
from a disregard of this natural law.
In quantity, food may be taken in excess or in deficient amount; if
the former, symptoms of gastric disturbance soon show themselves,
with lassitude, loss of mental and physical energy, sleepiness, dulness,
irregularity of the heart's action, dull, heavy headache, which is
usually frontal, constipation, and, frequently, deposits of urates in the
urine. A deficiency of food, at times merely the result of a disinclina-
tion to eat, produces loss of weight, physical and mental exhaustion,
and results, sooner or later, in a state of general malnutrition, which
becomes an important factor in the development of any inherited
predisposition to disease.
The digestive process consists of an elaborate series of mechanical
and chemical action, so intimately related to each other that imper-
fect or abnormal action on part of any of them necessarily gives rise
to disturbances throughout the entire series. Hence, anything which
prevents the proper performance of mastication gives rise to indiges-
tion; imperfectly formed or decayed teeth, a swollen tongue or tonsils,
abscesses and tumors in the oesophagus or larynx, may produce
marked gastric disturbances. Obstructions or dilatations anywhere
in the alimentary canal have a like effect, such as tumors and con-
strictions at the orifices of the stomach or in the intestines, dilatation
of the stomach, or adhesions of the intestines. Spasms, constituting
an excess of action, and paralysis, being a deficiency of action,
586
A SYSTEM OF MEDICINE.
obstructions by foreign growths, cicatrices anywhere in the alimentary
canal, and all other conditions which interfere with a proper per-
formance of mastication, deglutition, and defecation, have the same
effect.
Since each of the secretions of the various glands which take a part in
the process of digestion performs a certain portion of the work which
no other secretion can perform, it is evident that an abnormal con-
stituency of these secretions, leading to imperfectly performed chemical
changes, must give rise to disturbance by passing onward in the ali-
mentary canal food not in proper condition to be acted upon efficiently
by the secretions with which it later comes in contact. We know, for
instance, that the insoluble starches are converted into soluble and
diffusible sugars by the action of the saliva and of the pancreatic
juice. If this step in the digestive process is not properly performed,
either on account of the insufficient supply of saliva or because of a
vitiated condition of this secretion, the food, when taken into the
stomach, is not in a proper condition for gastric digestion, and, fre-
quently repeated, this must necessarily give rise to indigestion. It is
understood that these abnormal states of the secretions, producing the
imperfect chemical changes which we are now discussing, depend
upon perverted nervous influence, abnormal blood supply, or altered
conditions of the blood itself, but we do not yet know under what
conditions they occur.
The symptoms of indigestion are varied and characteristic. We have
fermentation of food, with a long train of symptoms directly due to
fermentation, and fully described hereafter. Characteristic gastric
disturbances occur, such as pain, weight, fulness, and distension in
the gastric region. The appetite becomes deranged, and thirst is
usually experienced. There are disturbances in the intestinal tract,
as pain, flatulence, diarrhoea, or constipation, and we find secondary
trouble in the nervous system, as neuralgia in different parts of the
body, headache, irritability, fretfulness, mental depression, and moodi-
ness. There are alterations in the urinary secretion; the organs of
circulation, the respiratory apparatus, and the generative organs are
variously affected, and a state of malnutrition soon prevails. Not
unfrequently the symptoms which occur in remote parts of the system
are more marked than the gastric disturbances proper, and, on the
other hand, many of the symptoms here enumerated may occur when
gastric digestion is perfectly normal, but when the disturbance arises
in the intestinal canal. Vertigo, for instance, a frequent accompani-
ment of gastric derangements, is very commonly caused by intestinal
flatulence.
A functional disturbance, which is of frequent occurrence in affec-
tions of the stomach, and one worthy of careful consideration, is pain,
varying from a slight uneasiness at the stomach to most intense suffer-
DISEASES OF THE ORGANS OF DIGESTION.
587
ing; it is usually located at the epigastric region, though it is also
often referred to the hypochondriac or umbilical region. The pain is
rarely confined to a circumscribed spot, but frequently radiates upward
or downward, or into the back, shoulders, or hypochondria. The
neuralgias, for instance, present a tendency to attack, in the most
erratic manner, various localities; cancer and ulcer have severe dorsal
pain; dyspepsia has pain and tenderness in the muscles of the chest
and back, particularly under the shoulder-blades. The causes of pain
are manifold. The neuralgic pains are often due to derangements in
some remote organ, and are of frequent occurrence in diseases of the
uterus or ovaries, in pericarditis, and occur quite commonly as con-
comitants in menstrual disorders; they are also associated with exist-
ence and passage of gall-stones, abdominal aneurism, etc. Not unfre-
quently, general constitutional disturbances, accompanied with im-
paired nutrition, produce neuroses of the stomach, in which case the
neuralgia improves as we succeed in relieving the cause. Purely
nervous gastric pain is rare; it is found in hysteria, hypochondriasis,
and similar conditions. The presence in the stomach of irritating
foreign bodies gives rise to spasms of the muscular coat and, hence,
to pain. Sharp foreign bodies and corrosive poisons produce pain by
the more or less extensive injury done to the structures of the stomach.
The presence of indigestible food, of acrid substances, the result of
fermentation, of marked distension from gas, and of bile in the stom-
ach, produce the same effect. Purely inflammatory conditions, while
giving rise to considerable distress, do not by any means cause the
intense suffering and the severe and continuous pain resulting from
cancer or chronic ulcer, which in their growth either destroy branches
of nerves, or, by the formation of cicatrices, produce pressure upon
nerves; when the latter give rise to obstruction of the pylorus, they
cause spasmodic action of the muscular coats, and thus act as a most
important factor in the production of pain in the stomach. Not unfre-
quently, severe pain in the stomach is caused by the irritating proper-
ties of acid secretions from the gastric mucous surface, a condition
which, at times, stubbornly resists the best directed and most perse-
vering treatment.
The pain of indigestion is not unfrequently mistaken for pain in the
abdominal muscles, perhaps of a rheumatic character, for the epigas-
tric pain which depends upon diseases of the spine, or for the intes-
tinal pain, in the transverse colon, which depends upon distension
from flatulence. The pain in the abdominal muscles should be recog-
nized without very much difficulty; a superficial tenderness and an
aggravation from motion usually determine the diagnosis. With
epigastric pain which depends upon functional diseases of the spine,
there is an absence of gastric disturbances, superficial tenderness on
pressure, and disappearance of the pain from deep pressure; the hys-
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A SYSTEM OF MEDICINE.
terical diathesis is commonly marked, and by following the course of
the nerve affected, other painful points are readily found. In organic
diseases of the spine we must be guided by the existing perversion of
sensation and motion in the lower extremities, the sensitiveness of the
spine to pressure, heat and cold, and by the general relief experienced
from rest. Pain in the transverse colon, arising from flatulent disten-
sion, is usually most severe in the hypochondriac region, and is liable
to extend through the sigmoid flexure. They are not only migratory
abdominal pains, due to flatulent distension in the bowels, but the
contractions in the intestines may be felt by the hand, and borborygmi
are constantly heard. The diagnosis of neuralgic pain from the pain.
which depends upon organic lesions of the stomach, depends on one
hand upon the more frequent occurrence of neuralgia in women, espe-
cially in early life, and on the other upon the uniformity with which
the pain of organic diseases of the stomach occurs soon after eating,
and the promptness with which it is relieved by emptying the stom-
ach; in the latter case, the pain is also likely to be confined to a well-
defined locality, and is promptly increased by pressure.
The secretions of the stomach may be excessive or deficient in
amount, or perverted in quality. The secretion may be of an acid or
of an alkaline character; it is presumed that the former is furnished.
by the glands of the fundus and of the body, and the latter by glands
situated at the pyloric region, lined with columnar epithelium. Excess
of secretion is chiefly due to nervous disturbance. It is not clearly
understood under what conditions an excess of acid or alkaline secre-
tions may be had; the presence of an excess of acid in the stomach
is, however, more frequently the result of fermentation than of hyper-
secretion. Whenever digestion is delayed by an imperfect supply of
gastric juice, or food in a state of fermentation is introduced into the
stomach, or when obstruction of the pyloric orifices exists, causing
retention of food in the stomach, or when the digestion of starchy
substances during mastication has been imperfectly performed, fer-
mentation takes place, giving rise to the formation of lactic, butyric,
and acetic acid, and of gas, consisting of carbonic acid and of volatile
carbo-hydrogens, or of sulphuretted hydrogen. Perversion of secretion
occurs chiefly in uræmia and in diabetes; in the former, urea or car-
bonate of ammonia, and, in the latter, sugar have been found in the
secretions of the stomach. Diminution or arrest of secretion is of
very frequent occurrence, and follows profound nervous disturbances,
sudden depression, great exhaustion, physical or mental, occurs as a
sequela of long-continued disease, of the privation of food and water,
and is not unfrequently found associated with the existence of intes-
tinal worms, of constipation, and of other conditions which will be
enumerated in their proper place.
The functional disturbances of movement consist chiefly of paralysis
DISEASES OF THE ORGANS OF DIGESTION.
589
of the muscular coat of the stomach, either from enervation or from
over-distension, causing dilatation; and, secondly, of vomiting. Both
subjects possess special importance, and are treated in full hereafter.
VOMITING.
Vomiting is produced by the action of the muscles of the diaphragm,
of the abdominal walls, and of the longitudinal fibres of the stomach.
The contraction of the first two sets of muscles produces pressure
upon the stomach; the longitudinal fibres of the stomach, contracting
simultaneously, dilate the cardiac orifice, and draw the stomach toward
the diaphragm. If, during these contractions, the cardiac orifice re-
mains closed, retching is the result. The contents of the stomach may
be ejected, without the participation of the muscles of the abdomen
and thorax, in which case eructation results. Eructations occur chiefly
in infants; in grown persons they consist in the ejection of gas or of
fluids, depending upon irritation or distension of the stomach, and,
in many cases, they become almost habitual.
The act of vomiting is produced by an excitation of the vomiting
centre, located, according to Budge, in the right corpus striatum. The
co-ordination of the movements rests within a nerve-centre on a floor
of the fourth ventricle in the medulla oblongata, from which the im-
pulses are sent by the intercostal, phrenic, and the pneumogastric
nerves.
Vomiting may be caused by excitation of the great nerve-centres or
by reflex action, or by peripheral irritation from the various viscera
of the body. Among the cerebral causes we may enumerate nearly
all the diseases which affect the brain or its membranes, such as can-
cer, tubercle, inflammations, hæmorrhage, apoplexy, and so forth; also
Menière's disease; injuries to the brain or head, such as blows or violent
concussions, are very likely to excite vomiting. The same effect is
produced by the action of narcotic poisons upon the brain, and by the
disordered conditions of the blood which are found in typhus, yellow
fever, cholera, and even in the cold stage of intermittent fever, not to
forget certain functional disorders of the nervous system which result
from fright or shock, and the pain caused from hurts or operations.
Unpleasant odors, the sight of nauseating objects, and even the
thought of them, act upon the brain through the nerves of special
sense, and produce nausea and vomiting. General nervous derange-
ment of a functional character, as found in hysteria, long-continued
swaying movements of the body, also the sight of objects in motion,
very frequently result in vomiting. Car-sickness and sea-sickness are
a common experience in travel, and are probably due to disturbances
of the vomiting centre through irritation of the optic nerve.
The causes which constitute peripheral irritation from different
590
A SYSTEM OF MEDICINE.
viscera embrace an almost interminable list of different diseases which
produce irritation of the nerve branches that control the various
organs. Irritation of branches of the glosso-pharyngeal nerve, sup-
plying the soft palate, root of the tongue and pharynx, whether by
tickling with finger or feather, or by inflammatory action in those.
parts, produces vomiting; the same effect is caused by irritation of
the gastric branches of the vagus and of the sympathetic, and of the
nerves which supply the liver, gall-duct, intestines, kidneys, bladder,
uterus, and ovaries. Vomiting by irritation of the gastric nerves may
be produced by irritation or inflammation of its wall, or from the
presence of irritating substances either introduced or found in the
stomach; it may be the result of a congested or catarrhal condition;
of softening of the mucous membrane; of the presence of poisons or
of scirrhous affections; of distension from gas, liquids, or any other
source; of pressure from within or without, as from hernia or tumor.
Any persistent pressure upon the stomach, such as is made by tight
lacing, or by pressure of the stomach against hard benches or tables,
in the pursuit of mechanical occupations, may produce this symptom.
Severe paroxysms of cough have the same result, due, probably, in
part to muscular contraction and pressure, and to the interruption of
the circulation, giving rise to congestion of the vessels. Among the
more remote conditions which may produce vomiting as a reflex
symptom, we may mention: hepatitis, the passage of biliary calculi,
obstruction of the intestine, strangulation, intussusception, peritonitis,
nephritis, renal calculus, either in the pelvis of the kidney or escap-
ing by the way of the ureters, vesicular inflammation, uterine affec-
tions, pregnancy, ovarian inflammation.
Diagnosis. In a diagnostic point of view the characteristics of
the matter vomited are of especial interest. The food ejected is fresh
and unchanged, save as affected by mastication, when the vomiting
depends upon nervous irritation; evidence of fermentation in the
ejected food furnishes conclusive evidence that it has been retained.
in the stomach for a considerable period of time. At times the vomited
matter is thick, glairy, tenacious, or frothy; again, it contains alcohol,
with various acids, such as butyric, acetic, and lactic acids. Since food
is longest delayed in case of pyloric obstruction of the stomach, it is
during the existence of this condition, so commonly associated with
dilatation of the stomach, and particularly favorable to the indefinite
retention of food, that we find the most positive evidence of decay
and fermentation; torula cerevisia and sarcina ventriculi are found
in the scum which rises on the surface of the vomited matter. The
presence of bile is of no diagnostic value; the presence of mucus in-
dicates a catarrhal condition, and pus may be found, and is found
only, when there exists ulceration of the submucous coat, unless it
has been emptied into the stomach from other sources, or has been
DISEASES OF THE ORGANS OF DIGESTION.
591
swallowed through the œsophagus. Fæcal matter may be vomited; if
so, it is an evidence that a portion of the intestine-usually the colon
—communicates with the stomach, or that fæcal matter is forced up-
ward on account of obstruction in the intestines. It has been affirmed
that the presence of cancer-cells in vomited matter may be demon-
strated, but recent writers discredit the assertion.
The question often arises during the occurrence of vomiting, espe-
cially when it takes place suddenly, whether the symptom arises from
cerebral or from reflex causes; the question is one of great practical
importance and not always easy of determination. Usually, the con-
comitant symptoms, and their relation to each other, throw light upon
the subject. The following points should also be borne in mind: If
vomiting depends upon gastric irritation, it is almost sure to be pre-
ceded by nausea, and to be accompanied with pain and discomfort in
the epigastric region, and with derangements of digestion, such as
loaded tongue, thirst, discomfort in the bowels, flatulence, headache,
and commonly constipation or diarrhoea; the nausea, pain, and
headache which precede and accompany indigestion, are usually re-
lieved with great promptness by the emptying of the stomach. In
cerebral vomiting, on the other hand, nausea and epigastric pain are
very rarely experienced; the tongue is usually clean; there are likely
to be present vertigo and headache, disturbances of vision, mental
confusion, loss of memory, disorders of sensation and of motion, and,
possibly, convulsions and coma. These symptoms develop gradually,
and are liable to occur when the vomiting depends upon disturbances
of the gastric functions; neither are they relieved by vomiting.
Treatment. Since vomiting per se is merely a symptom, it is
evident that the first step to arrest it is to determine its cause, and
then to remove the same.
In vomiting which depends upon irritation of the brain, cold appli-
cations to the head may be found useful, and the old school in such
cases frequently practice successfully the application of leeches. It is
also recommended, and the advice is excellent, to administer by the
mouth small bits of ice. Our chief reliance, however, on account of
the promptness and permanency of their action, is in the administra-
tion of the carefully selected homoeopathic remedy. Among those
likely to be called for we may mention Belladonna, Hyoscyamus,
Helleborus niger, Aconite, Opium, Apium virus, Cocculus, Arnica,
Laurocerasus, and others.
The vomiting arising from gastric irritation is usually relieved with
reasonable promptness. Common sense suggests the prompt evacua-
tion of the stomach if the difficulty is due to the presence of poisons.
or of irritating substances.
There are practitioners who, in the latter case, advise entire reli-
ance upon the indicated remedy; it seems, however, more in accord-
592
A SYSTEM OF MEDICINE.
ance with good judgment to insure the prompt removal of the offending
substance than to allow it to remain in the stomach for an indefinite
period, and by its continued presence to give rise to much inconven-
ience and suffering, if not to absolute danger. The offending substance
once removed, a few doses of the proper remedy will at once allay the
entire difficulty. Lukewarm water with mustard, freely administered,
usually causes prompt emesis. Copious draughts of hot water alone
are often not only quite sufficient to produce vomiting, but have an
admirable effect by diluting the irritating substance and by affording
much relief to the irritated mucous surface. If the vomiting depends
upon an inflamed condition of the stomach, our sole dependence lies.
in appropriate medication. If decomposition of food, or fermentation,
has set in, the wisdom is urged of administering light doses of sulphu-
rous or of carbolic acid. The action is purely antiseptic, and the pro-
priety of this treatment is based upon the fact that even violent
vomiting will not eject from the stomach the small remnants of fer-
mented matter which, remaining, continue to excite fermentation in
food which is later taken into the stomach. Persons who are subject
to frequently occurring attacks of vomiting may receive a certain
measure of relief by avoiding lying on the right side, since in that posi-
tion the weight of the stomach produces unpleasant sensations, the
gas cannot readily escape, and the sickness is likely to be kept up for
an indefinite period. The list of remedies from which to select in this.
class of cases is almost unlimited; those most frequently useful are
ARSENICUM, Ipecacuanha, BRYONIA, NUX VOMICA, Phosphorus, Ignatia,
Opium, Argentum nitricum. For special indications the reader is re-
ferred to the various chapters on special diseases of the stomach.
The vomiting of sea-sickness is often exceedingly unmanageable;
the use of wines, coffee, and other stimulants has been advised; some
authorities insist upon almost total abstinence from food, while others
urge the opposite course. From personal experience, based upon the
advice of an old navy surgeon, the writer thinks the best results are to
be obtained by constantly repeated and copious draughts of luke-warm
water, with perfect quiet until the stomach regains its tone; the use of
warm water renders the repeated vomiting easy and painless by keep-
ing the stomach well filled. An occasional dose of Cocculus is of much
service; the patient should assume a reclining position, and keep the
head lower than the body.
The vomiting of pregnancy belongs to the field of obstetrics, and its
discussion can find no place here. Careful attention to diet, and the
patient exhibition of the right remedy, greatly lessen the suffering
from this source, and largely reduce the rate of mortality. The fol-
lowing remedies are of importance in the treatment of the vomiting of
pregnancy: Alumina, ARSENICUM, BRYONIA, Calcarea carb., Chamo-
DISEASES OF THE ORGANS OF DIGESTION.
593
milla, Carbo veg., CoccULUS, Conium, IPECACUANHA, Kali bichr., LAURO-
Cerasus, Nux vomica, PHOSPHORUS, PULSATILLA, Veratrum.
ATONIC DYSPEPSIA-ATONY OF THE STOMACH.
Definition. A disorder of digestion which is characterized by a
general depression of the vital force, and by a feeling of heaviness,
vague distress or uneasiness at the stomach, following the ingestion of
food. The disease develops gradually, and naturally assumes a chronic
course; it is not attended with fever or with violent disturbances of
the digestive functions; it depends upon a loss of tone of the stomach,
due to inherited tendency or to some cause which exerts a depressing
effect upon the vital force, and leads to imperfect secretion of gastric
juice or to enfeebled muscular movements of the stomach.
Etiology.—Inherited Predisposition.-Scrofulous children, or chil-
dren born of parents who are sufferers from nervous irritation, indi-
gestion, and a lack of vitality, due either to inherited tendencies or to
habits of living, are particularly liable to suffer from this affection.
Such persons in childhood need not necessarily give evidence of a
marked weakness of digestion or of disease of the stomach; having
passed the period of adolescence, they are, however, liable to betray
this inherited tendency by symptoms of indigestion which, at first of
slight severity, become more and more marked, and soon give rise to
much inconvenience, depending in extent largely upon the temper-
ament of the individual, the judgment used in the care of health, and
upon occupation; carelessness of living, excesses of various kinds, and
sedentary occupation naturally favor the rapid development of the
complaint; it is not unfrequently the case that such persons have be-
come confirmed sufferers long before they have reached the prime of
life.
Age has considerable influence in the same direction. As people.
grow old, the different glands of the body lose, to a large extent, their
power of secretion, the muscular fibre possesses less tonicity than
in the prime of life, and disorders of digestion readily show themselves.
Sex is not an important factor; men, however, are particularly sub-
ject to inflammatory diseases, while the predisposition of women to
nervous affections, or to diseases in which the nervous system plays
an important part, makes it probable that they more commonly suffer
from derangements of digestion which are of nervous origin.
It is safe to state that any condition of the system which is asso-
ciated with, or depends upon, a state of general depression of the vital
forces, predisposes to atonic dyspepsia. Extreme heat, for instance,
particularly in moist countries, develops a marked tendency to this
complaint.
Certain pathological conditions act as predisposing, and in another
VOL. I.-38
594
A SYSTEM OF MEDICINE.
sense, as exciting causes. A gastritis, acute or chronic, as well as al-
most any chronic lesion of the gastric mucous membrane, is pretty
sure, under favorable circumstances, to be followed by atonic dyspepsia;
the same result may obtain from the existence of various structural
changes, ulcers, growths, or from dilatation or atrophy of the gland itself.
Errors in diet are the most fruitful exciting cause, especially when
the stomach is already weak, or when an inherited tendency to dys-
pepsia exists. Irregularity in the time of taking meals, prolonged
fasting, eating too often and in too much haste, and eating between
meals, deserve mention here. It is a remarkable fact that people of
more than average intelligence frequently suffer severely from indi-
gestion simply because they seem not to realize the folly of partaking
of food long before the contents of the stomach, from a previous meal,
have had time to pass into the duodenum. The habit of drinking to
excess at the table is also very pernicious, and the effects of moder-
ately warm drinks, thus excessively taken, are particularly disastrous.
A general relaxation of the mucous membrane results from their use,
and is quite as mischievous as the diluting and weakening of the gas-
tric juice which result from the copious admixture of drink. The too
liberal use of condiments, spices, narcotics, and of stimulants gener-
ally is sure to destroy, sooner or later, the integrity of the stomach; a
long-continued diet of tea, soups, and other liquids, resembles in its
general effect that of warm drinks. The imperfect mastication of
food, whether the result of carelessness, or due to defects of the teeth.
or of the mouth, greatly impairs the vigor of digestion, and, if long
continued, is almost sure to result in harm. Fenwick (Quain's "Dic-
tionary of Medicine ") says, "The writer has found that only nineteen.
per cent. of those who were not dyspeptics confessed to the habit of
eating very quickly, whilst among the sufferers from gastric disorders,
fifty-one per cent. were in the habit of improperly masticating their
food."
It is undoubtedly true that the poor often suffer severely from dys-
pepsia, owing to insufficient supply of food, to long fasts imposed
upon them by stern necessity, and, above all, to the use of food utterly
unsatisfactory in quality. The wealthy, with all the luxuries at their
command, are, however, not exempt from indigestion. The tempta-
tion to indulge too freely in the pleasures of the table, to eat oftener
than required, or to indulge in food which they have not sufficient
vigor of body to digest, in many persons of this class leads to a com-
plete exhaustion of the digestive powers, while in others it results in
the establishment of gout and other fashionable diseases.
The integrity of the gastric juice depending upon a sufficient supply
of the proper material from the blood, it is evident that any condition
which impoverishes the blood, thus making it impossible for this fluid
to furnish the material necessary to preserve the integrity of the gas-
DISEASES OF THE ORGANS OF DIGESTION.
595
tric juice, must lead the way to eventual and serious harm to digestion;
hence it is that anæmia, chlorosis, copious discharge from the mucous
or serous membranes, hæmorrhages and excessive suppuration rarely
continue for any length of time without seriously affecting digestion,
and leading to atonic dyspepsia. Long-continued sexual excesses are
also a fruitful cause of this affection by the great waste of matter, and
by the wear and tear which this vicious habit entails upon the nervous
system.
It is well known that the condition of the nervous system greatly
affects the digestion; any marked nervous disturbance promptly modi-
fies and, not unfrequently, arrests this important process. Mental
strain exhausts vitality, lessens the secretion of gastric juice, and in-
terferes with proper muscular action. The shock of a sudden, violent
emotion, a fit of passion, a paroxysm of violent anger, a fright, an
unexpected and great joy, all these are known to have arrested in-
stantaneously the process of digestion, leading, in some instances, to
very serious results. In a similar manner, the demands made upon
the active business man, the worry of the ambitious, the anxieties of
professional life,-in fact, everything partaking of the nature of an ex-
cess, are productive of stubborn and long-continued derangements of
the stomach. These causes are most operative during the years which
constitute the prime of life, and the perplexities caused by them, with
the attending loss of sleep, and the constant excitement of the entire
system, furnish the reason why men more often suffer from atonic dys-
pepsia between the age of forty and fifty-five,-the time of life when
ambition is most active, and the efforts to achieve success are most
persistent and daring.
On the other hand, it is not unusual to find dyspepsia resulting
from utter indolence on the part of those who, by virtue of wealth and
position or from hopeless idleness, feel not called upon to make any
exertion. The utter apathy of such a life seems to produce a condi-
tion of depression little less serious than the strain of continued over-
work, and quite likely to produce similar results.
Pathology.—Atonic dyspepsia is practically a functional disturb-
ance, and we have not a clear idea of those pathological changes which,
it is presumed, are always associated with even mere functional dis-
turbances. We are justified in looking for the evidences of faulty
nutrition, but cannot satisfactorily describe them. An atrophy of the
gastric mucous membrane, with thinness and transparency of the walls
of the stomach, fatty degeneration, and structure-waste, have been ob-
served in many cases. According to Handfield Jones, Habershon, and
Wilson Fox, such conditions, in many instances, were found to be re-
placed by a greater or less amount of fibro-nucleated tissue, associated,
frequently, with distinct loss of power in the digestive function during
life. Dr. Fenwick asserts that in such cases the digestive powers of
596
A SYSTEM OF MEDICINE.
the mucous membrane after death are also markedly diminished.
Bearing in mind the fact that the tendency to degeneration which, on
one hand, is characteristic of old age, and, on the other, frequently the
result of previously existing inflammatory conditions, is important in
properly estimating the meaning of the structural changes which have
been observed after death, we are forced to admit that the pathology
of atonic dyspepsia is wholly speculative, and is likely to remain so
for an indefinite period of time. Whenever we find appreciable
structural changes, well-defined and unmistakable, they are the result
of a deeper-lying disease of which atonic dyspepsia simply formed an
incidental part.
Symptoms.-Atonic dyspepsia develops gradually and slowly, with
a decided tendency to the chronic state. The first symptom is usually
a sense of fulness and distension at the stomach which appears soon
after a meal, continues for one, two, or three hours, and either gradu-
ally disappears of its own accord, or is relieved by the next meal.
There is rarely present much pain, the feeling of fulness at the stom-
ach being accompanied only with a vague epigastric uneasiness.
Later, these symptoms become more troublesome. The pain at the
stomach rarely grows severe, but flatulence, at first in the stomach,
later throughout the alimentary tract, becomes very annoying. There
is connected with it a sense of constriction, an oppression of the upper
chest, which is most keenly felt at the middle sternum, and is relieved
by repeated eructations of gas and small amounts of undigested food.
Usually these eructations are not rancid, though at times butyric-acid
fermentation occurs. The flatulence frequently produces distressing
dyspnoea, which is most painful in persons somewhat predisposed to
functional disturbance of the heart. In such subjects the difficulty
of breathing is, at times, excessive, the action of the heart irregular,
moderate indulgence in the pleasures of the table produces violent
palpitation, and the slightest exercise, especially when taken soon after
a meal, causes markedly irregular action of the heart. Not unfre-
quently such persons find it difficult to go to sleep, and if of a nervous
and apprehensive turn of mind, fancy that they are the victims of an
incurable heart disease and are liable to die at any time. In other
instances the sufferer wakens in the middle of the night, the heart per-
forming remarkable antics, and he is obliged to lie awake for an hour,
or more, before sleep again comes to him. It is often remarked by this
class of sufferers that the heart seems suddenly to turn a somersault.
Flatulence is a common feature of atonic dyspepsia, and constitutes
one of its most annoying symptoms. In some cases, the distension at
the stomach is distressing. A choking sensation is bitterly complained
of. Pressure upon the stomach and violent motion of the body are
occasionally followed by eructations, affording much relief. As the
gas passes along the alimentary canal, it produces tightness and neu-
DISEASES OF THE ORGANS OF DIGESTION.
597
ralgic pains in various parts of the body, and borborygmi may readily
be heard on external pressure. The pains produced by the accumula-
tions of flatulence are not always severe, but at times they radiate to
the shoulders and to the left arm, and are of sufficient severity to pro-
duce serious discomfort, resembling, somewhat, a light attack of angina
pectoris. The differential diagnosis from this far more serious affec-
tion rests upon the fact that the paroxysms of pain resulting from
flatulence almost always occur soon after a meal, and lack the aggra-
vation from motion which is characteristic of the latter.
The epigastric distress is rarely accompanied with tenderness in the
epigastric or in the abdominal region, as the case may be; it is relieved
by pressure, unless there exists that general tenderness of the surface
which is, at times, found in drunkards and in hysterical persons; but
even in such cases, hard, deep pressure is readily borne, and affords.
relief.
The appetite is poor, and, at times, complete aversion to food exists.
Occasionally, the patient craves indigestible food, starchy substances,
and fats, soups, broths, and, in some instances, boiled unsalted meat,
which, if eaten, produce violent suffering. Vomiting is not a usual
symptom, although consumptives and persons suffering from hysteria
are likely to be troubled with it. When vomiting occurs, the matter
ejected is watery, and contains particles of undigested food.
Thirst rarely exists, and many patients practice total abstinence
from drink. Some cases seem to receive temporary relief from copious
draughts of cold water. The tongue, which in inflammatory condi-
tions of the stomach is usually red and pointed, is pale, flabby, broad,
showing indentations from the teeth. It is rarely heavily coated; this
pallor and a sponginess of the sore parts extend to the lips and gums.
The soft portions of the throat are usually relaxed, producing thick-
ness and hoarseness of the voice, and hawking and spitting.
The breath presents no characteristics. It is rarely offensive, and,
at times, is of a sweetish odor. The pulse is slow, feeble, and com-
pressible, and easily excited; it partakes of that irregularity and ex-
citability of the action of the heart which has already been described.
The surface of the body is cold, clammy, and moist. The hands
and feet are cold and damp; the complexion is sallow and dirty, and
there is usually perceptible loss of flesh, which, however, does not
compare with the remarkable emaciation found in organic diseases of
the stomach. The urine is pale, of low specific gravity, and gives a
pale sediment; urea is deposited in cases which are characterized by
great tissue-waste.
The intestine partakes, in most cases, of the general condition of
atony. Constipation is of almost constant occurrence, although diar-
rhoea is observed in exceptional cases. The stools are solid, dry, scy-
balous, at times frothy from fermentation. In some instances, as ob-
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A SYSTEM OF MEDICINE.
served by Fenwick, they contain pieces of fibre-like tissue resembling
worms. The constipation, the result chiefly of the existing atony,
tends to aggravate the existing difficulties. It aids in still further
deranging the appetite, assists in the formation of gas, and, in some
cases, by the irritation of the hard stool and of the undigested food
upon the mucous membrane, produces inflammatory action which
causes additional sufferings, complicates the case, and increases the
difficulties of a cure.
The nervous system partakes of the general state of depression and
irritability; especially do those patients suffer seriously in whom ner-
vous depression is in itself the probable cause of the entire difficulty.
The patient suffers from great languor and weakness, especially from
heaviness of the legs. His sleep is hopelessly disturbed; he becomes
irritable, peevish, and irresolute, is unable to exert himself, or to con-
centrate his thoughts for any length of time upon any one subject, and
a vigorous and long-continued effort of body or mind soon becomes
an utter impossibility.
Diagnosis. The diagnosis of atonic dyspepsia usually presents no
especial difficulties. The absence of thirst and fever, the condition of
the tongue, as already described, the absence of pain in the epigastric
region, and of tenderness to pressure, aided by a careful study of the
causes of the disease, will usually determine the diagnosis of the case.
Occasionally, the physician is puzzled in differentiating between a
catarrhal state of the gastric mucous membrane and dyspepsia, the
more so since frequently attacks of inflammation of the stomach oc-
cur in the course of dyspepsia. The following are to be borne in
mind: In gastritis the pain is marked, and there exists great tender-
ness to pressure; in atonic dyspepsia the patient rarely complains
of much pain in the epigastric region, save as an uncomfortable feel-
ing of distension exists as the result of flatulence, and there is no ten-
derness upon pressure. In gastritis there is much vomiting, acidity,
and heartburn; in dyspepsia these symptoms are not prominent, and
frequently do not occur at all. In gastritis the urine is high-colored,
loaded with lithates; in dyspepsia it is pale, and deposits urates when
great tissue-waste exists; at times, in dyspepsia, it shows deposits of
oxalates and phosphates.
It is scarcely necessary to point out the differentiation between
atonic dyspepsia and the more serious organic diseases of the stomach,
as ulcer, cancer, and so forth. The entire history of the case, the
appearance of the patient, the cachexia unmistakably shown in the
advanced stages of the disease, the intensity of the suffering and the
violence of all the symptoms in the case, the frequently-occurring
vomiting, all these symptoms point with almost unerring certainty
to the graver lesions of the stomach.
DISEASES OF THE ORGANS OF DIGESTION.
599
Prognosis. The prognosis of the average case of atonic dyspepsia,
not complicated by serious constitutional disorders, under well-di-
rected treatment, is favorable, although the patience of both patient
and physician are frequently taxed not a little before permanent
improvement takes place. When the functional disturbance of the
stomach occurs in persons of advanced age, or when in those younger
in life it follows a long-continued state of inflammation of the stomach,
it is wise to make a somewhat guarded prognosis. Cases frequently
occur in which the disease of the stomach depends upon the exist-
ence of a deep-seated difficulty in some other organ of the body; if
so, common sense suggests that no cure of the dyspepsia can be looked
for until the first cause of the difficulty is wholly removed.
The existence of atonic dyspepsia should always enlist the interest.
of the attendant physician. Nutrition must necessarily become im-
paired wherever this atony exists for any length of time, and it is safe
to assume that such a state of impaired nutrition may often act as ex-
citing cause in the formation of diseases of the kidneys, lungs, heart,
and other organs, when such organs are already by inheritance or dis-
ease predisposed to abnormal states. In anæmic patients the occur-
rence of atony of the stomach may well excite apprehension, and for
self-evident reasons the physician must concentrate his energy in the
direction of furnishing relief to the sufferer by establishing to the fullest
extent of his power the integrity of the digestive organs.
Treatment.—In view of the fact that patients suffering from
atonic dyspepsia are likely to remain under the care of their physi-
cian for some considerable length of time, and that a favorable termi-
nation of the case depends largely upon the patience and willingness
of the invalid to implicitly follow directions given, it is of the last im-
portance that the physician should, first of all, use all means to gain
the full confidence of the patient; the more friendly and the closer
the relation between patient and physician, the better able is the latter
to determine the primary cause of the difficulty, and he can do much
toward relieving unpleasant surroundings, unhappiness in family re-
lations, anxiety of mind, and even business vexations, which con-
stantly provoke, irritate, and aggravate the patient's condition. This
accomplished, so far as lies in his power, the physician concentrates
his attention upon the peculiarities of the case before him, supporting
the patient morally and physically, prescribes the diet best adapted
to the wants and digestive powers of the patient, sees to it that proper
regimen is had, and, last of all, administers the specific homeopathic
remedy.
The subject of the patient's diet is of the greatest importance. It is
necessary to remember that idiosyncrasies of patients very often de-
termine the food upon which to place them. In a general way, how-
ever, it is well to observe a few general rules which may be embodied
600
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A SYSTEM OF MEDICINE.
in the following propositions: Do not let the stomach be overloaded
by eating too much or too often; insist that the patient masticates.
thoroughly, takes abundance of time for his meal, drinks a small
amount only, and then of cold water, cold milk, or cold tea; let the
food be cooked plainly but carefully, and not too highly seasoned;
see that the time of the meal be made the occasion of a pleasant family
gathering; let the conversation be bright and stimulating, and the faces
cheerful and happy. After the meal is finished, let the patient ab-
stain for some length of time from all exercise, physical or mental,
and devote himself to quiet and rest.
Occasionally cases occur where the patient demands, and should
have, food oftener than once in five or six hours. These cases are ex-
ceptional, but when they occur, and this is particularly the case in per-
sons who are anæmic, it is best to give food in small amounts and at
short intervals. Under all circumstances, it is well to bear in mind.
the fact that very long intervals between meals are fully as dangerous
as eating too often; long fasting weakens greatly the powers of diges-
tion, and in many instances is responsible for the existence of gastric
atony.
As a general thing, dyspeptic persons must avoid fried dishes and
grease; they should eat no soup or broths, no condiments, no fresh
bread, no young potatoes, no pastry, and they should avoid heavy
stimulants. Vegetables are wholesome, if judiciously selected; they
must be fresh, thoroughly ripe, and well cooked. In some cases a vege-
table diet creates flatulence; if so, it is best to discontinue it for a
time, and to use freely in its place reasonable quantities of lemon-juice.
Dr. Charles Gatchell, speaking of persons troubled with flatulency
and eructations of gas from the stomach, states that this difficulty may
be corrected by eating only vegetable food at one meal, and animal
food at another. Roasts are preferable to boiled meat. Of the meats,
mutton, beef and game are to be recommended; pork, veal, salted or
canned meats must be avoided. Fresh eggs can easily be used with
impunity. Chicken is readily digested by many, while in others it
produces serious disturbance.
Of the vegetables and fruits, turnips, parsnips, onions, cucumbers,
watermelons and cantaloupes are to be avoided. Peaches, grapes, straw-
berries, prunes, if ripe, are rarely harmful. Bread must be well baked:
it should never be eaten fresh, and is best two or three days after
baking; it does nicely when toasted. Pastry, nuts, pickles and cheese
are to be avoided. Sugar must be eaten in moderate quantities, and
light starchy puddings should be eaten with caution, for frequently
they produce acidity of the stomach; under no circumstances should
they be sweetened richly. Of drinks, moderate amounts only can be
taken; they should be cold, and it is better to drink between meals.
than at the table. The value of milk as an article of diet in the great
DISEASES OF THE ORGANS OF DIGESTION.
601
majority of cases is well understood; it is both refreshing and nourish-
ing. Cocoa also deserves mention as a palatable and nutritious drink;
chocolate, if well made, is too rich for the stomach of the dyspeptic.
Wines are recommended by European writers, especially claret, hock,
champagne, and sherry. American practitioners, as a class, discoun-
tenance the use of wines, but it cannot be denied that in many in-
stances much good has been done by their judicious use. In nervous
and utterly prostrated persons, particularly in nervous women, a small
amount of iced champagne frequently exerts a most pleasing effect
upon the stomach. A glass of heavy claret often affords wonderful
help to the overworked business man or professional man, and, used
wisely, produces none but desirable results. Some patients prosper
upon a diet largely made up of corn-meal and clabbered milk. The
latter is an article of diet not appreciated as it deserves to be. It
should be served cool with cream or nutmeg, and is really a delicious
dessert dish, much used in Europe by all classes. Crackers, made
after the formula of Dr. Charles Gatchell, in the practice of the writer
have done excellent service. The following directions are given for
their preparation (Gatchell, Diet in Disease): "Take of wheat meal
one quart; butter, one tablespoonful; water enough to make a very
stiff dough. Beat this dough with a potato-masher or rolling-pin for
half an hour, laying it on a bread-board for the purpose. Roll it into
a ball, and beat it out over and over again. Now roll it out very thin ;
cut into round shapes; prick with a fork, and bake in a quick-oven.
The wheat meal should be especially prepared for these crackers. If
no other is to be had, use good brown flour. To secure a good article,
buy some good wheat, take it to the mill, and have it ground. Let the
bran be sifted out, but leave the middlings and flour together, and you
have a good wheat meal.”
Raue (Special Pathology and Therapeutics) gives an excellent bit of
advice when he urges in an acute case of dyspepsia to follow the cravings
of a patient, but to mistrust morbid appetite in chronic cases.
The regimen of the dyspeptic must be looked after. As already
indicated, the state of the patient's mind is of the utmost importance;
whatever can be done to make him content and happy, to unload his
mind of anxiety and worry, helps just so much toward putting him
forward on the road to recovery. Over-work and indolence must be
alike avoided. The occupation should be agreeable; if it is not already
so, a change should be made, if at all possible. The patient must be
taught to cultivate an intimate acquaintance with the open air and
sunshine. He must sleep in a cool room with an abundance of fresh
air in it. Exercise in the open air is of the last importance. When-
ever possible, easy travel, and in desirable companionship, should be
recommended. Travel necessitates particular care so far as diet is
concerned, but has a most satisfactory effect upon the nervous system
602
A SYSTEM OF MEDICINE.
and upon the mind of the patient. Dyspeptics have a tendency to
brood upon their troubles, and everything they see is colored by the
reflection of their own gloom; slowly moving from place to place,
viewing constantly changing scenery and studying new faces, helps
people get outside of themselves, and this one point alone is often of
the greatest importance. When travel under desirable conditions
cannot be had, boating, yachting, occasional hunting, camping-out,
etc., are to be recommended. If lack of means or of time stand in
the way, the benefits of the gymnasium are almost always available.
In all these outdoor exercises the patient must be carefully cautioned
against undue exertion, and must be instructed never to indulge to
the point of exhaustion. After exercising, he must rest until thoroughly
refreshed, when a light meal may be taken. Bathing may be recom-
mended, but must not be carried to excess. If the patient is suffi-
ciently robust to bear a short cold bath, a sponge-bath, or a shower-
bath, he may safely indulge in it twice a week, but not oftener. The
bath should always be of short duration, and friction should be thor-
oughly used after the bath. The habit of directing patients to take
such baths daily, is decidedly unwise; the effect is exhausting rather
than stimulating. In some cases, a daily sponge bath, rapidly admin-
istered, and followed by the necessary amount of friction with a bath-
towel and flesh-brush, has been found advantageous. Dyspeptics who
possess the necessary means may be sent to the seashore or to mineral
baths. A brief residence at the seashore gives many of the advantages
of travel the faces seen and the surroundings had are constantly
changing, and the air usually is bracing. A residence at mineral
baths, especially at some of the gaseous and chalybeate springs, may
be recommended, not so much on account of the medicinal virtues of
the waters, as because of the intelligent care usually exercised by the
physician in charge, so far as attention to regimen and to the diet of
the patient is concerned.
Therapeutics.-Since a very large number of remedies of the
homœopathic materia medica may, under proper conditions, be ex-
hibited with advantage, and since all remedies to be considered must
present a totality of symptoms closely resembling those described
under the symptomatology of atonic dyspepsia, the most pertinent
symptoms only need be pointed out here.
Nux vomica.-The great usefulness of Nux depends very largely upon its
peculiar action upon the nervous system. It is best indicated in persons who suffer
from loss of muscular power, and who, from close confinement, over-work, and indul-
gence of the appetite, have utterly broken down the nervous system. The patient
is cross; easily irritated; has a sallow, yellowish complexion; suffers from dull frontal
headaches in the morning, and becomes incapable of making a prolonged mental ex-
ertion; fulness and distension after a meal; sensitiveness to pressure, and tightness
around the waist; lassitude; nausea; vomiting of food and bile. Taste, especially in
the morning, is insipid, bitter, or sour. Appetite is wanting. He cannot eat bread,
milk, or acids. Symptoms are usually aggravated from eating. Constipation, with
DISEASES OF THE ORGANS OF DIGESTION.
603
useless urging (?) to stool, and with feeling of constriction about the anus; pyrosis;
borborygmi.
Ignatia.—Ignatia, in some respects, partakes of the general sphere of action of
Nux. Weariness and great nervous prostration, with general depression, are charac-
teristic of Ignatia. Bloating after meals, with hiccough from eating or drinking. The
patient has no appetite, and suffers from musty eructations. Or, if appetite is toler-
able, he eats a few mouthfuls, and then feels thoroughly repleted. There is a faint,
gone feeling at the stomach, even when there is no bloating; flatulence and colic,
however, occur frequently, and especially at night. Breathing is oppressed and sigh-
ing, with tendency to palpitation of the heart, most marked at night. Periodical
cramps occur at the stomach, occasionally with canine hunger and qualmishness; pres-
sure in the region of the vertex, which shifts toward the forehead; the stools are hard,
and are passed with great difficulty.
Phosphorus. An excellent remedy in persons who have masturbated or in-
dulged in sexual excesses. There is great prostration, with a dry, earthy-colored
tongue; dryness of the throat, sour taste and eructations. Regurgitation of food after
taking it. Cold drinks are grateful to the patient and relieve the burning at the
stomach; as soon as they warm in the stomach they are ejected with a return of the
painful symptoms. There is constant, loud, annoying rumbling of gas in the bowels,
which seems not lessened by the frequent emissions of gas which take place. Heat
and congestion of the head; soft, watery, painless diarrhoea.
Calcarea carbonica.-A very valuable remedy, frequently overlooked i
particularly useful in cases which have run a long time. The tongue is coated thick,
whitish-yellow. The patient has no appetite, and has a positive dislike to meat and
warm food, what he eats he wants cold. There is considerable thirst, and the taste is
bitter and putrid-sometimes sour. After a meal there is much bloating and fulness
at the stomach, which is somewhat sensitive to touch, accompanied with heat and pal-
pitation of the heart. The stomach symptoms are often relieved for the time being
by a profuse accumulation of saliva in the mouth. Hemicrania in the morning, with
a weakening tendency to cold sweat, especially of the feet.
Bryonia.—Bryonia, according to Trinks, relieves the pressure on the stomach,
caused by irregularity in diet, eating indigestible food, bread not enough baked,
coffee, brandy, or bad beer. It comes on when the stomach is empty, as well as when
it is full; the patient complains of a pressure at the pit of the stomach as of a heavy
stone there. It lasts from two to four hours, sometimes longer, and goes off after
copious eructations. In worse cases the so-called water-brash is accomplished, or there
is a great deal of acidity generated, which shows itself by sour risings, heartburn,
and vomiting of very sour and acrid mucus. In severe cases there is much sensitive-
ness of the stomach to external pressure. Bryonia is very useful during hot and moist
weather. The mouth and throat are dry; the tongue yellow; everything tastes bitter.
An icteric condition prevails. Severe and characteristic headache. Fluids disagree.
The patient wants wine, coffee, acids. He is restless, irritable, vehement. Constipa-
tion without desire for stool.
Carbo veg.-Charcoal restores the vitalizing purity of the blood, rouses the
sinking energy of the nervous system, and purifies the secretions of the mucous mem-
brane; in the hands of the careful prescriber it is one of the most valuable remedies
in the treatment of indigestion. It is particularly useful in the case of persons who
have lived high, and who suffer from excess of flatulence, sour and rancid, with epi-
gastric soreness as result of this flatulence, and with a tendency to diarrhoea. There
is a great aversion to food, with occasional violent spasmodic contractions in the epi-
gastrium, worse at night and, sometimes, after breakfast; relieved by eructations.
Vomiting rarely occurs, but the patient suffers much from nausea, particularly in the
late forenoon. He is temporarily relieved by taking stimulating drinks. There is
trembling and a sense of weight at the stomach. The patient can drink no milk,
loathes meat, and especially fat meat. Fright, cold, and heat bring on the symptoms.
Hiccough; gas moves upwards.
Hydrastis. Great lassitude and debility; weak digestion, with heavy, hard
thumping pain and fulness of the chest, and dyspnoea; large, flabby tongue, looking as
if covered with slime; dull, frontal headache; empty, gone, faint feeling at the
stomach; palpitation of the heart with strong pulsations in the pit of the stomach ;
sour and bitter eructations; pyrosis; symptoms worse from eating; constipation;
stools hard, knotty, followed by pain and faintness; hæmorrhoids; chronic discharges
from mucous surfaces.
604
A SYSTEM OF MEDICINE.
Arsenicum.-An excellent remedy in persons who have enfeebled the stomach
by the persistent use of ice-cold drinks, tobacco, and excesses of various kinds, and
whose nervous system gives evidence of great exhaustion. The remedy is most fre-
quently indicated when the condition of the stomach borders upon inflammation or
when gastritis actually exists. The stomach is exceedingly irritable and refuses to
retain food. Heartburn; gulping up of acid fluids; excoriating the throat; the epi-
gastric region is full, and there is a tenderness to pressure; nausea and vomiting,
relieved by hot drinks; tongue red, hot, rough, irritated, pointing to inflammatory
action; the patient can take no animal food; tendency to diarrhea; pulse feeble, quick-
ened, irregular; cold extremities, and general coldness and dryness of the surface,
interrupted with fever-flashes and shiverings; fits of sudden weakness; great thirst;
drinks often and little at a time; symptoms worse from drinking cold water.
Argentum nitricum.-Like Arsenicum, useful when there exists much irri-
tation of the mucous membrane. There is excessive flatulence; the stomach seems
ready to burst; copious eructations, which are accomplished only after persistent effort
and are very violent; fluid seems to run right through the entire alimentary canal
without stopping; the patient is in a condition of apathy; the mental symptoms are of
great importance, and consist of marked depression, great anxiety and worry, with an
impulse towards self-destruction, the result of excesses.
China. Of great value in the treatment of patients suffering from anæmia or
malarial poisoning. Continued feeling of acidity; sinking at the epigastrium, re-
lieved for a time by eating, but returning soon; coldness in the stomach; desire for
pungent and refreshing things and stimulants; can eat no farinaceous food; slowness
of digestion, with cramps and pressure after eating; vomiting of ingesta; thin, dark,
offensive diarrhoea after eating; ill humor; indisposition to make any exertion; heavi-
ness. When the symptoms of malarial poisoning are especially well defined, with
enlargement of the spleen, the lower triturations of the Sulphate of Quinine are fre-
quently very useful.
Pulsatilla. - Tongue thickly coated with white, rough fur; taste pasty, as of
spoiled milk; absence of thirst; repugnance to warm dishes; pain after eating, worse
from drinking cold water. Said to cure dyspepsia brought on by the use of fat and
rich foods. Hiccough, colic, rumbling in the bowels, slow stools.
Anacardium.-Useful in cases where the difficulty depends upon complete
prostration of the nervous system, and atony of the stomach, as the result of long-
continued and excessive mental labor, resulting in exhaustion of the nervous force.
The nervous symptoms predominate, hence the constant desire to eat at any time, day
and night, without receiving relief.
Asa fœtida.-Especially adapted to nervous and hysterical women. Its most
important symptom is the enormous meteorism of the stomach. As in Argentum
nitricum, the patient finds it difficult to relieve himself of the flatulence which refuses
to pass downwards and must be ejected from the stomach. General hypersensitive-
ness, both physical and mental; craving for wine.
Aurum.-Useful in cases suffering from flatulence, palpitation and pain of the
heart, and pain in the chest, with great mental depression, burning and pressure in
the stomach, with hot rising. Palpitation relieved by eructations of gas.
Berberis.-Valuable in cases with a tendency to bilious dyspepsia, muscular
rheumatism, melancholy, listlessness, mental depression, great pro-tration, causing
perspiration from slightest exertion. Offensive, metallic odor from the mouth, which
is dry and sticky.
Bismuth.-Sweetish, metallic taste in the mouth; thirst for cold drinks, with
immediate vomiting of cold water taken. Burning and pressure of the stomach after
eating, confined to a circumscribed small spot, forcing the patient to bend backwards;
eructations of offensive odor.
Ipecacuanha.-Indicated by the presence of constant sickness at the stomach,
with tendency to vomit and other characteristic symptoms.
Iris vers.—An important remedy when the condition borders upon an inflam-
matory state. The symptoms are violent, with great burning distress in the stomach;
vomiting of water and very sour fluid; belching of wind, and yellow, watery discharges
from the bowels, the passage of which causes extreme burning in the anus and rectum.
Kali carbonicum.—“Well adapted to corpulent, aged people, who are con-
stantly chilly, never perspire, have pallor of the face, oedema of the upper eyelids,
great desire for sweet things, bloatedness of the abdomen, dryness of the mucous sur-
faces, dry, hard stool, turbid urine, constant chilliness."
DISEASES OF THE ORGANS OF DIGESTION.
605
Lachesis. The patient can endure nothing tight about the throat or elsewhere;
feels as if a foreign body were in the throat, which he must swallow but cannot move;
offensiveness of the stools; sour. foul, cadaverous taste; perceptible trembling in the
epigastric region. This remedy is often indicated from the totality of the symptoms,
but in the experience of the writer, and of many others, rarely does satisfactory work.
Leptandra virg.-Useful in cases with complication of the liver; flat, pappy
taste; nausea with death-like faintness upon rising; great distress in stomach and
liver, worse from drinking water; black, papescent, foetid, and profuse stools, followed
by prostration.
Lycopodium.-Dyspepsia with intestinal flatulence; desire for food from sen-
sation of weakness in the stomach; can eat but little on account of the enormous dis-
tension from flatulence; brick-dust sediment in the urine; nervous exhaustion.
Mercurius.-Liver complications; foul, sweet, brassy, saltish, bitter taste in the
mouth, especially in the morning; wants spicy food, cold drinks, wine, brandy; sus-
picious, sad, vehement mood; slimy mouth; ptyalism.
Nux mosch.-An excellent remedy in nervous, hysterical women. Great
flatulence, which seems brought on not only from eating but by any excitement; ver-
tigo; brain feels loose in the skull; fair appetite, but a few mouthfuls satisfy.
Podophyllum.-In cases with intestinal complications; in morning diarrhoea,
followed by weakness; desire for acids; dryness of mouth, throat, and tongue; sour
eructations; bilious complications.
Sepia. To be consulted whenever women suffer from menstrual or uterine diffi-
culties; sour, putrid taste; aversion to meat; desire for sour things; emptiness in the
stomach, with anguish; palpitations; weakness and weariness of legs; sour eructa-
tions; the sweat of the axillæ and feet exhales a very strong odor.
To be consulted: Arnica, Hepar, Sulphur, Rhus tox., Esculus, Alu-
mina, Cina, Cocculus, Magnesia muriat., Sanguinaria, Agaricus, Anti-
monium crudum, Colocynth., Fluoric acid, Dioscorea, Silicea, Ra-
tanhia, and the mineral acids.
Auxiliary Treatment.-The remarks made under regimen.
practically form the chief part of the auxiliary treatment. Cases
occur in which much relief is given by the use of pure Pepsin, admin-
istered in doses of from 3 to 5 grains, about a half-hour before a meal
is taken.
Electricity, in some cases, may be advantageously employed. It is
serviceable, according to Beard and Rockwell, first, by improving the
nutrition of the tissues of the organs; secondly, by improving the
nutrition of the brain, spinal cord, sympathetic, and entire nervous
system. The faradic current is usually preferable to the galvanic,
because it acts more vigorously on the muscles, "and hence produces
more purely mechanical effects with possible exercise of all the deep
tissues. It may be safely said that we know of no treatment more
sure to relieve the leading and concomitant phenomena of dyspepsia
than general faradization and central galvanization. In connection.
with these we sometimes use galvanization of the sympathetic, pneu-
mogastric, and the spine. General faradization relieves nervous dys-
pepsia, not so much by the virtue of its influence on the stomach-
although it directly affects the stomach-as by its influence on the
nervous condition of which dyspepsia is a symptom. The stomach
may be indirectly galvanized through the pneumogastric in the neck,
or directly faradized by applying large electrodes, with very fine
606
A SYSTEM OF MEDICINE.
pressure over the back and abdomen, thus passing the current
directly through the organ. If the organs are not diseased, they will
bear a fairly strong current, which may be applied on an average of
from three to ten minutes, either keeping both electrodes in a fixed
position, or moving one slowly over the surface of the organ operated
upon.
NEUROSES OF THE STOMACH.
Synonyms.-Cardialgia, Gastralgia, Gastrodynia, Morbid sensi-
bility of the stomach, Cramps of the stomach (?).
Definition.—A disturbance of the stomach characterized by pain,
vomiting, derangement of appetite, and perversion of function; the
disease is functional, and depends upon constitutional disorders capa-
ble of producing this condition as a reflex symptom or of so lowering
the standard of vitality as to cause marked general depression, with
nervous irritability and excitability.
Etiology. The neuroses of the stomach, like many other func-
tional disturbances, find their most prolific causes in those conditions.
of the general organism which are characterized by an impairment of
nutrition, predisposing to, and resulting in, functional disturbances of
a local character either as reflex symptoms or as a necessary sequence
of the general derangement. As a general proposition, it is safe to
assert that pain at the stomach, with the concomitant symptoms.
described in this chapter, is likely to occur in any person whose
nutrition is already impaired by a constitutional disturbance of long
standing, and of a temperament which, by virtue of an inherited or
acquired nervous irritability, is predisposed to the neuroses.
A vigorous constitution, supported by habits of prudence and by a
wise economy of vital resources, is likely to resist the effects of extra-
neous inimical influences and the wear and tear of grave responsi-
bility and worry, while a constitution feeble by inheritance, and
barren of vitality, is sure to break down under the same strain.
Hence, in estimating the probable effects of exciting causes it is
necessary to pay due consideration to the amount of vitality at the
disposal of the patient for resisting the effects of untoward influences;
that which merely staggers for a moment one individual will lead to
hopeless prostration in the case of another. All depressing influences,
as grief, anxiety, long-continued excitement, jealousy, mortification,
anger, and fear, if long-continued, are peculiarly liable to produce.
functional disturbance in the digestive sphere; but they are much
more sure to give rise to serious disorders in this direction in persons
already weakened or in those naturally very sensitive, than in those of
a robust temperament. The same applies to long-continued and hard.
intellectual employment, and it is on this account that professional
DISEASES OF THE ORGANS OF DIGESTION.
607
work and the life of the student are by no means fit employments
for those physically weak, but require for their successful pursuit the
most robust and vigorous constitutions. Severe physical labor, also,
if pushed too far, may tend to establish neuroses of the stomach,
although it is much less likely to bring about this result than are
those labors which involve wear and tear of the nervous system.
Whatever depresses vitality and impairs nutrition deserves study
in this connection. The loss of animal fluids from hæmorrhages and
other causes, anæmic conditions, and bad feeding belong here. All
excesses must be considered; the abuse of stimulants, for instance, and
sexual excesses and irregularities, among the latter more especially
the practice of onanism, are prolific causes of nervous disturbances
which sooner or later affect the stomach.
Diseases of the nervous system generally may act as predisposing
or exciting causes of neuroses of the stomach. Hysteria, with the
host of abnormal nervous phenomena which this term covers, fur-
nishes as large a quota among women as hypochondriasis does among
men. It is, indeed, very rare that we find a well-defined case of
hysteria which does not present many of the gastric disturbances
which are here considered, and those at all experienced in the treat-
ment of hysterical women will quite readily accept the statement
made by Briquet that of 358 cases of hysteria treated by him within
a certain length of time all but 30 had suffered more or less severely
from gastralgia.
Malarial poisoning, no doubt, frequently results in the production
of these neuroses.
In such cases it is not unusual to find that the
gastralgia is distinctly intermittent, and this fact becomes a diagnostic
point of no little value. The gouty diathesis is also held by many
writers to predispose to these affections; it seems, however, that the
stomach symptoms often found in connection with gout partake more
of an inflammatory nature than of a purely functional disturbance.
The effect of tobacco, more particularly when chewed, deserves con-
sideration; it acts powerfully upon the nervous system, and tobacco
chewers frequently suffer severely from cramps and other painful
disturbances of the stomach. Among those causes which produce
neuroses of the stomach as a purely reflex symptom, a variety of
disorders may be mentioned, even trivial conditions, sometimes far
removed, for affections of the external ear and of the teeth at times
affect in a marked manner the functional integrity of the stomach.
Diseases of the kidneys, constipation, inflammation of the testicles,
gall-stones, but more particularly diseases which involve the female
reproductive organs, and above all the uterus, are almost sure, sooner
or later, to give rise to stubborn and painful neuroses of the stomach.
Structural diseases of the stomach also, as cancer and ulcer, are
classed in the same category by many writers. It is, however, diffi-
608
A SYSTEM OF MEDICINE.
cult to draw the line where those symptoms which properly belong
here are the result of purely functional disturbances, and where they
are due to inflammatory action with characteristic tissue changes.
Age and sex are not without influence. In women, the appearance
and the cessation of the menstrual function mark the time at which
disturbances in the sexual and reproductive sphere are most common,
and where disturbances of the nervous system, and among them
neuroses of the stomach, are very likely to take place. The occur-
rence of this class of gastric affections in women is alike rare before
puberty and after the climacteric period has passed. In some women
who are sufferers from abnormal, and especially from painful, men-
struation, attacks of gastralgia, at times very severe, mark the recur-
rence of every menstrual period, the patient, during the intervals,
enjoying almost perfect immunity from them. Men are most likely
to suffer from neuroses of the stomach at that time of life when they
are called upon to bear the heaviest burden and to exert themselves
to the utmost. It is at the time when atonic dyspepsia breaks down
so large a number of business and professional men that they also
suffer most frequently from neuroses; in fact, the same conditions
predispose to both affections, and atonic dyspepsia is in itself a potent
predisposing cause of gastralgia.
Hereditary predisposition and idiosyncrasy deserve notice. It is
readily seen that persons who, by inheritance, are predisposed to
atonic dyspepsia, must likewise be excellent subjects for the develop-
ment of neuroses. The matter of idiosyncrasy hardly admits of
explanation; we merely know that certain persons are so organized
that in them serious effects are produced by agents which in all others
appear perfectly or comparatively harmless. Cases are on record
where strawberries, one of the most delicious and harmless of fruits,
produced intense suffering at the stomach, and where honey could
not be eaten without giving rise to violent functional disturbance of
the stomach.
Bearing in mind the intimate relation between neuroses of the
stomach and those constitutional disturbances which are characterized
by impaired nutrition, general weakness, sensitiveness and nervous.
excitability, it is evident that everything which tends to produce such
a state must be considered a predisposing cause of neuroses of the
stomach. Disease of the nervous centres frequently produces gastric.
disturbances very like those here described; and affections of the
spinal cord may give rise to violent epigastric pain. These condi-
tions will receive fuller consideration elsewhere.
Pathology. In the entire absence of positive and characteristic
anatomical changes, the pathological questions involved in the dis-
cussion of this subject do not admit of a satisfactory solution. We
simply understand that mal-nutrition of the nerve-centres plays a very
DISEASES OF THE ORGANS OF DIGESTION.
609
important part, and that such a condition invariably results in de-
stroying the harmony of their action-producing an excess of activity
in one direction, and a corresponding measure of deficiency of action
in another. We also know that lack of coördination and inefficiency
of function go hand in hand with nervous excitability, resulting in a
large variety of disturbances of sensation and motion, with a long train
of morbid phenomena the relation of which to each other, as to cause
and effect, is not understood. The theories of Anstie, and of other
authorities, do not even approximate a satisfactory solution of the
questions which arise in connection with this subject. The same ap-
plies to the organic changes which, it is presumed by many close.
observers, must result from a long-continued and profound functional.
disorder in the stomach, as well as in other portions of the human
organism.
Symptoms. The neuroses of the stomach are characterized by
pain, vomiting, derangement of appetite, and perversion of function.
Pain. This symptom is usually preceded by evidence of depression,
faintness and nausea, possibly vomiting, and, at times, a flow of saliva
into the mouth; in other cases it is the first symptom indicating the
approach of the attack. The nature of the exciting cause usually de-
termines the character of the preliminary symptoms; it varies from a
feeling of annoying fulness and distension to a pain of agonizing in-
tensity, accompanied with violent constitutional disturbances, and
embracing in character an infinite variety of manifestations; it is
boring, shooting, gnawing, burning, pressing, tearing, or cramp-like,
frequently radiating upward into the chest, directly backward into the
spine, or into the hypochondriac regions. If severe, it is accompanied
by signs of extreme suffering. The patient bends backwards; the face
is distorted from the severity of the pain, and at times is almost hip-
pocratic. The pulse becomes irregular, the extremities cold, and the
surface bathed in cold, clammy perspiration. Pressure, if light, usually
aggravates; deep and hard pressure as often gives marked relief. In
rare cases great sensitiveness to pressure exists, and the patient objects.
even to the weight of his covering. The suffering at times is so intense
that the patient faints, and it is stated that even convulsions have
occurred. At times the pain is paroxysmal, and between the parox-
ysms the patient enjoys a few moments of rest. In light cases the
paroxysms of pain are of comparatively short duration; in severe.
cases the suffering is continuous, and may cover a period of many
hours of the greatest agony. The abdomen, during these attacks, may
be retracted or distended. If the attack depends upon nervous irri-
tability or is the result of great exhaustion, eating sometimes affords.
considerable relief; and it is characteristic of the neuroses of the
stomach that this relief may be had from eating food which, in in-
flammatory conditions of the stomach, would not only be speedily re-
VOL. I.-39
610
A SYSTEM OF MEDICINE.
jected, but would intensely aggravate the suffering, while, on the other
hand, more harmless and bland foods are not kindly borne. Ex-
ceptions to this rule, however, occur; when the pain is due to uterine
disturbances, or when it exists as a reflex symptom, the introduction
of food is followed by such keen suffering that the patient utterly re-
fuses to partake.
The
paroxysms of pain are not accompanied by an elevation of the
temperature, and involve no danger to life.
In less violent cases, pain, varying from a feeling of fulness and
weight to a gnawing and tearing pain of considerable severity, is likely
to occur a few hours after food has been taken, and in such cases it
may be due less to an irritation of the sensory nerves of the mucous
membrane of the stomach than to a spasmodic, cramp-like action of
the abdominal muscles. The pain here radiates in different directions,
and marked distension of the stomach from flatulence is a symptom
which frequently occurs. The attacks usually terminate with belching
of wind and vomiting of water or mucus, followed by copious urina-
tion, profuse perspiration, soreness at the epigastric region, and ex-
haustion, which is in proportion to the severity of the attack.
Vomiting sometimes occurs independent of pain. In the majority
of cases it is preceded by nausea and is not accompanied with many
suspicious concomitant symptoms. It is readily differentiated from
the vomiting of gastritis or of organic disease of the stomach; in the
latter, vomiting is persistent, long-continued, and accompanied with
intense pain, while in the neuroses it is neither so long-continued nor
very severe. In many cases these attacks are followed by intervals of
several days during which the condition of the stomach seems in every
respect normal.
pa-
The vomiting of hysteria and, more especially, of pregnancy, when
it becomes continuous, constitutes a source of great danger to the
tient. It may occur immediately after eating or within a few hours
after the ingestion of a meal, or it may be most violent early in the
morning before food is taken, in which case a small amount of food,
for instance a glass of milk, taken before rising, frequently lessens
the severity of the symptom. The matter ejected in such cases is often
undigested, containing little bile or mucus, while at other times much
acidity of the stomach is shown. With few exceptions, the appetite
in these cases remains good. The patient vomits, only to return again
to the table, and to again eat heartily. The quality of the food taken
does not materially affect the frequency or the persistency of this type
of vomiting, which becomes dangerous only as it may lead to an in-
flammatory condition of the stomach, or to anæmia, and even starva-
tion. It is on this account that the stubbornness with which hysterical
patients occasionally refuse to take nourishment becomes a source of
annoyance to their attendants and of danger to themselves. The
DISEASES OF THE ORGANS OF DIGESTION.
611
tongue, in these cases, is rarely coated, and usually presents merely
that broad, large, pallid and flabby condition which is so generally
found in functional gastric disorders.
The perversions of the appetite which occur in connection
with these cases are of interest. There is likely to be either a crav-
ing for the most extraordinary and unwholesome substances, or there
exists a ravenous hunger which cannot be satisfied even by repeated
indulgence in enormous quantities of food. Among the strange
cravings noticed in such persons, a desire for chalk, charcoal, brick,
and pins are the most harmless. It is utterly useless to reason with
such patients about the folly of yielding to so strange an impulse, for
they are bound to satisfy it at all risk. Whenever there exists bulimia,
this ravenous craving for large amounts of food, the patient suffers.
severe pain, nausea, and goneness at the stomach, unless his hunger
is satisfied. It must not, however, be understood that indulgence in
eating affords relief. On the contrary, faintness and distress occur
soon after eating. These hysterical cases present also a tendency to
diarrhoea, with flatulence and evacuations of liquid, undigested stool.
Frequently the stools occur before eating, and are delayed if food is.
taken before the patient leaves the bed. A sudden start, a slight
fright, in fact, nearly all sudden emotions, are likely in such cases to
bring on a sudden stool or an attack of diarrhoea. It is quite prob-
able that Trousseau is correct in attributing this condition to an irri-
tability of the muscular coat of the intestines and of the stomach, by
which the food is propelled onward with abnormal rapidity. This
tendency to diarrhoea in hysterical patients is the more interesting
since other cases of neuroses of the stomach are usually accompanied
with a fairly normal condition of the bowels, or with a somewhat con-
stipated habit.
The constitutional disturbances which are found in connec-
tion with this class of gastric affections are chiefly those of general ener-
vation and nervous depression, or such symptoms as are associated
with the disorders upon the existence of which the gastric neurosis
depends.
Neuralgic pains in various parts of the body, and of various degrees
of intensity, are of quite common occurrence. If the functions of the
nervous system are badly deranged, even paralytic symptoms may
appear. Sleep may be profound, but is unrefreshing, and the patient
often wakes in the morning tired and sore; it requires an effort to
rise, and he feels better only after stirring about for some little time.
Others suffer more or less from insomnia; while still another class
drop into a quiet sleep, only to waken during the night hungry and
faint, and unable to again sleep until the hunger has been satisfied
or exhaustion forces heavy, unrefreshing, or restless sleep; the latter
symptom often occurs in those suffering from hysteria.
612
A SYSTEM OF MEDICINE.
Cases of hysteria, melancholia, chlorosis, and others of the same
class, present a vast array of concomitant and characteristic symptoms
peculiar to those conditions, a recital of which has no place here.
Diagnosis. In differentiating between the neuroses of the stomach
and organic diseases of the same organ, we must depend largely upon
the character of the pain and of the vomiting, upon the coating of
the tongue, the presence or absence of fever, and the existence of such
constitutional disturbances as have already been considered. With
the aid of all of these it is at times still exceedingly difficult to deter-
mine the presence or absence of gastric ulcer or cancer. Whenever
the symptoms described in this chapter occur in a person who is suf
fering from great exhaustion, nervous depression or excitability, from
well-marked symptoms of hysteria, melancholia, or of those constitu-
tional disorders which have been mentioned as actiological factors;
when in such cases the gastric difficulties improve or grow worse as
the general condition of the patient improves or grows worse, the ex-
istence of organic lesions is counterindicated. The existence of neu-
ralgias in various parts of the body strongly favors the diagnosis of a
neurosis, although intercostal neuralgia may exist in ulceration of the
stomach, and dorsal neuralgia may be felt alike in neurotic and in
organic affections of the stomach. The pain which depends upon a
nervous disorder remits, while in an inflammatory condition it is in-
clined to be more constant. In severity gastralgia exceeds the pain.
of any other affection of the stomach, save that resulting from the
action of a corrosive poison. The pain is usually most violent when
the stomach is empty, and is relieved by eating. The reverse is the
case in the pain of inflammation: it is not usually intense, it is aggra-
vated from eating, and subsides when the irritating food has been
ejected. In pain of a nervous origin articles of diet are borne which
would violently increase the distress of a patient suffering from an
inflamed stomach; in the former, bland articles of food often disagree;
in the latter they alone may be kindly borne. In the former, heavy
pressure relieves; in the latter, it intensifies. It is to be remembered
that in ulcer or cancer of the stomach perfect remissions of pain are
not of unusual occurrence.
The vomiting due to a neurosis is usually casy, and recurs again
and again; in organic diseases of the stomach vomiting is more pain-
ful, but ceases when the irritating substance has been ejected. The
neuroses are accompanied with no fever; in acute gastric catarrh fever
exists; in ulcer and cancer fever is rarely noted, unless incidental in-
flammation occurs. The tongue, in the neurotic condition, is pale,
flabby, large; in inflammatory conditions it is dry, red, pointed, cracked;
in ulcer or cancer it is changeable.
A differential diagnosis of neurotic from gouty affections is diffi-
cult; the existence of burning and heat at the stomach, fever, and
DISEASES OF THE ORGANS OF DIGESTION.
613
other symptoms pointing to inflammatory action, would indicate the
latter. If gouty in its character, metastasis may occur to the joints,
producing in them characteristic symptoms; if the metastasis is fol-
lowed by relief of the stomach symptoms, such an occurrence would
at once determine the true nature of the difficulty.
Prognosis.—The prognosis, so far as danger to life is concerned, is
favorable; so far as it refers to a prompt and speedy cure it must be
very guarded, for the tendency of this condition is to run for an in-
definite length of time, and a cure may be a matter of years. Cases
occur where we have no repetition of an attack, but they rival in
rarity those cases in which a perfect cure follows at once the admin-
istration of the "right" remedy. Unfortunately, many cases have
been placed on record which must lead the inexperienced practitioner
to presume that the right remedy is not only easily found, but that its
administration is sure to be followed by a prompt cure. Undoubtedly,
a great number of these remarkable cures recorded are cases of a mis-
taken diagnosis; it is, however, a matter of congratulation to know
that remedies selected under the law of the similars enable the physi-
cian to produce results in the treatment of this class of affections
which, on the whole, are very satisfactory.
The duration of the neuroses of the stomach depends very largely
upon the nature of the exciting cause. If the latter be limited in
duration, the paroxysms of epigastric pain grow less violent, and dis-
appear as the exciting cause ceases to act; hence, violent attacks of
pain at the stomach which appear in hysterical patients recur less
frequently and with constantly decreasing violence as the age of the
patient advances.
The vomiting of pregnancy, when continuous, frequently becomes
the source of the greatest danger to mother and child, and in many
instances it becomes necessary to deliberately sacrifice the latter by
inducing an abortion in order to save the life of the former. In ex-
ceptionally obstinate cases of hysteria, where the anorexia is profound,
and the patient cannot be induced to take sufficient nourishment,
serious consequences result from the unwillingness or inability to take
food, and from subsequent inanition.
Treatment.-Nothing can be done directly to prevent the occur-
rence of these severe paroxysms of pain and of their attending symp-
toms, save to make every effort to establish a satisfactory state of
health, and to restrict and modify the operation of the constitutional
disturbances which are responsible for the existence of the local dis-
order. All measures which tend to establish a good digestion, a
healthful state of mind, and a fair measure of general health, must be
carefully observed; especial attention must be given to the diet of the
patient, and the directions given in the chapter on "Atonic Dys-
pepsia" should be carefully observed.
614
A SYSTEM OF MEDICINE.
Therapeutics.—-Phosphorus.-Oppression of the chest, proceeding from the
stomach, and worse after eating. Belching of large quantities of flatus after eat-
ing and during the attacks. Burning and gnawing pain in a circumscribed spot at
the stomach, which is very sensitive to the least pressure; the pain extends backward
to the spine, is increased by motion and eating, and is relieved by cold drinks and rest.
Gnawing pain at the stomach, relieved for a short time by eating. Vomiting of the
entire contents of the stomach; vomiting of pure blood or brown masses containing
blood; rising of swallowed food by the mouthful; great thirst during the paroxysms,
with aggravations of the symptoms from drinking, and vomiting as soon as the drink
has warmed in the stomach; weakness in the abdomen; palpitation.
Plumbum.-Pain which causes the patient to bend backward, and is relieved
by hard pressure on the stomach; it is accompanied with marked hardness of the
abdomen, which feels like a board; sensation as if the abdomen were drawn in, so that
it and the backbone seem to meet; feeling of constriction at the pharynx; hands and
feet cold.
Belladonna.—Gnawing, pressing pain, or a wrenching pain extending to the
spine, or a spasmodic tension which makes the patient bend backward, or stop breath-
ing, which appears to give relief. Tired feeling in the spine; the patient attempts to
rest the spine by bending backwards; pain is excessive, so that the patient becomes
unconscious, and threatens to go into convulsions. The face is bloated and congested;
congestion from disturbances or suppression of the menstrual functions; the symptoms
are aggravated by vomiting (a Belladonna plaster applied to the stomach not infre-
quently gives much relief).
Nux vomica.-Clawing and cramping pain, with pressure and tension between
the shoulder-blades; the pain radiates into the chest, or downwards into the abdomen,
producing uneasiness in the rectum, and the characteristic sense of constriction at the
anus; the anus is drawn in; pain worse from eating, from light pressure, better from
hard pressure, from bending backward, from vomiting; nausea; accumulation of water
in the mouth; heartburn; feeling as if a band were tied around the chest, with pain
radiating into the small of the back.
Argentum nitricum.-Gnawing, ulcerative, sore pain, which is confined to
a small spot between the xyphoid cartilage and the umbilicus, with sensitiveness to
slight pressure; from there the pain radiates into the back, hypochondria and shoulders.
Spinal irritation; worse from eating; great flatulence; often nausea with palpitation;
the pain increases and decreases gradually; when at its height, the patient finds relief
by making violent pressure with the clenched fist into the pit of the stomach.
Stannum. The pain comes on gradually, but is very obstinate; it extends to
the navel; is relieved by hard pressure. Sinking, gone feeling at the pit of the
stomach; canine hunger; great uneasiness, the patient walking about until weakness
causes him to desist, and finding relief from pain by walking.
Ignatia. Painful pressure as from a stone in the pyloric region, especially from
eating or at night; gnawing, cutting pain; weakness; faintness, and feeling of empti-
ness at the pit of the stomach, which is sensitive to contact; burning in the stomach;
regurgitation of food. The remedy is of peculiar value in the treatment of those hys-
terical cases where anorexia is almost absolute, and the gastric symptoms are grad-
ually intensified by this habitual starving. Frequent voiding of large quantities of
pale urine is also a common symptom. Ignatia is said to be a good remedy in the case
of habitual smokers.
Bryonia.-Pressure in the stomach right after a meal, as from a stone; pressure all
over the stomach, with soreness and tenderness in the epigastrium; feeling of bloated-
ness and oppression of breathing, with stitches in the stomach. Contractive, pinching
pain, relieved by eructations. All the symptoms are made worse by motion; character-
istic headache. In chronic cases the pain comes on even an hour or two after eating,
continues for several hours, and then wears off.
Ferrum.—Of especial use in anæmic subjects suffering very much from neural-
gic affections, and who are subject to cardiac uneasiness; atony of the stomach; heavy
pressure in the pit of the stomach; vomiting immediately following eating; not often
preceded by nausea; brought on by coughing and moving about; pain relieved by
vomiting; intolerance of milk.
Bismuth.-One of the chief remedies in the hands of the old-school physicians.
Pressure as from a load in one spot; heaviness; intense malaise with burning pain in
the spine; the patient bends back to find relief from it. Excessive pain in the back
and shoulders; water-brash; flatulence; prostration.
DISEASES OF THE ORGANS OF DIGESTION.
615
Arsenicum.—Particularly useful when the condition borders upon the inflam-
matory state. Gnawing, corroding pain, with pressure in the stomach as from a lump,
which sensation is confirmed by touch; violent burning with characteristic irritability
of the stomach, and vomiting. Pain relieved by drinking sweet milk.
China.-Bilious derangements. Distension in the region of the stomach, with
painful pressure after eating or drinking even small amounts; pain gets worse during
rest; better during motion; stupid, depressed, and indolent mood, particularly after
eating. Icteric symptoms. The sulphate of quinine is especially useful when par-
oxysms return regularly, and symptoms of malarial poisoning exist.
Dioscoria,-Useful in persons with weak digestion, with tendency to colic.
The remedy has a marked effect upon the nervous system of the abdomen, especially
the coeliac and umbilical plexus. Burning at the stomach, with sharp, pricking pain
and faintness. Pains radiate in all directions, and appear constantly in head and feet;
belching of large quantities of gas.
Pulsatilla.—Especially useful in persons betraying a tendency to digestive de-
rangements; feeling as if a large piece of food had lodged in the esophagus; also
over the hypochondria, then darting upwards into the chest, impeding respiration.
Characteristic gnawing at the stomach when empty; sour and bitter vomiting, and
absence of thirst.
Petroleum.-An excellent remedy in those cases where the patient experiences
relief by constant eating. The pain is pressing, drawing. Emptiness and weakness at
the stomach; water-brash.
Consult also the following: Asa fœtida, Calcarea carb., Cal. hypo-
phosph., Carbo veg., Chamomilla, Chelidonium, Colocynthis, Gelse-
mium, Leptandra, Lycopodium, Acid. phosph., Rumex, Veratr. alb.,
Cocculus, Iris, Lobelia, Sanguinaria, Aesculus, Acid. nitric., Sepia, Si-
licea.
The auxiliary treatment of the neuroses is practically embodied in
judicious attention to the hygiene and regimen, embracing also those
manifold special attentions to the constitutional causes of the neuroses
which will tend to modify and relieve them. When the patient does not
care to eat, simply because there is no desire for food, iced effervescing
drinks and a little champagne, or a little iced champagne, will fre-
quently be very grateful and help give tone to the stomach.
The persistent vomiting is often greatly benefited by adding to the
administration of the proper remedy, more especially in hysterical
patients, the douche, shower-bath and cold affusions; a few doses
of pure pepsine sometimes act very nicely. When vomiting has been.
long continued, it is an excellent plan to give very small amounts
of easily digested food at quite short intervals: the stomach thus gains
rest, while at the same time a certain amount of nourishment is intro-
duced into the system. It is often expedient to administer in this
manner very small amounts of milk, even a teaspoonful at a time,
at frequent intervals.
Counter-irritation, by means of sinapisms over the stomach, is oc-
casionally used with varying success. In the vomiting of pregnancy
the use of oxalate of cerium, in light doses, has of late become quite
fashionable, and the writer has seen several cases in the practice of
his colleagues in which happy results were obtained from its admin-
istration. The use of opium or of morphine, for the relief of intense
pain, is open to serious objections, and it can honestly be asserted that
616
A SYSTEM OF MEDICINE.
the skillful homœopathic prescriber is rarely called upon to employ it.
Nevertheless, cases occur in which the suffering of the patient is so
intense that a refusal to administer an anodyne would be simply in-
excusable. In such cases the salts of morphia are to be administered
in proper doses by the mouth or hypodermically.
Electricity has been employed with a fair measure of success. Erb
recommends its use, and indorses the method of Lube, who applies
the positive pole to the most painful part of the epigastrium, the
negative pole in the left axillary line, or more toward the spinal
column, and allows a strong stabile current (a current applied with
both electrodes in a fixed position) to pass for five to ten minutes.
Viziola reports a cure of a very severe case of hysterical gastralgia by
the application of the positive pole, the negative pole being kept in
the hand. Erb also commends treatment of the spinal cord, or of the
sympathetic and pneumogastric in the neck, as well as direct faradi-
zation of the gastric region, or the faradic brush to the epigastrium.
Rockwell and Beard state that their "results in gastralgia have thus
far been more satisfactory than in any other neuralgia." They cite a
very severe case of chronic gastralgia, of a periodic nature, of four
years' standing, relieved by galvanization after the failure of faradiza-
tion. In using the strong galvanic current, the positive pole was placed
on the back of the neck just above the seventh cervical vertebra, and
the negative pole was applied over the region of the stomach in order
to affect the solar plexus of the pneumogastric.
ACUTE GASTRIC CATARRH.
Synonyms.-Gastritis, Inflammatory dyspepsia, Gastric fever.
Definition. An acute disorder of the stomach, depending upon
an inflamed state of the gastric mucous membrane, characterized by
malaise, loss of appetite, nausea, vomiting, and intolerance of food
and drink.
Etiology. It is proposed to consider under acute gastric catarrh
that entire range of acute gastric disorders which lie between com-
mon acute indigestion and that rare, and nearly always fatal, condi-
tion, true acute inflammation of the stomach. The various names
used to describe this condition are alike inappropriate and mislead-
ing. The term "catarrh " should not be used in connection with the
gastric mucous membrane, because its functions differ materially from
those of all other mucous membranes, an abundant secretion of mucus
being a physiological function of the former, while it is pathological
in the latter; the term "gastritis," on the other hand, correctly used,
signifies a condition the gravity of which is out of all proportion to
the comparatively trivial disturbances which constitute what is more
commonly and incorrectly called acute gastritis.
DISEASES OF THE ORGANS OF DIGESTION.
617
Gastric catarrh, as the term is here employed, is of frequent occur-
rence. It usually depends upon some disturbance in the digestive
function caused either by a weakened state of the stomach, which
prevents normal digestion of healthful food, or by the introduction
into the stomach of food which is unwholesome, or which, by some
idiosyncrasy, cannot be tolerated in the particular case in question.
In either case the food is not digested, and soon becomes a foreign
body, producing more or less violent disturbance and irritation. A
stomach debilitated by pre-existing illness, or sympathetically affected,
perhaps by general ill health or by a profound mental or nervous
depression, may be utterly inadequate to the task of digesting even
light and simple articles of diet, and may thus suffer severely from
what, under other circumstances, would have produced no disturb-
ance whatever. The stomach suffers readily from the depressing
effects of grief, and any profound shock may suddenly arrest digestion,
and thus produce considerable inconvenience and even serious conse-
quences. Age is a predisposing cause of gastric catarrh; in the young
infant gastric disturbances constitute a fruitful source of danger to its
health and life; the decrepitude of old age forbids the indulgence in
articles of food which the stomach of a younger person readily digests.
Under certain circumstances, indulgence in a moderate amount of
perfectly healthful food may give rise to acute indigestion. More fre-
quently, however, unwholesomeness of the food taken is reponsible for
the disturbances which follow its use. Certain articles, as cheese, shell-
fish, hot bread, and others, tax severely the digestive powers of most
persons, especially if poorly cooked or richly seasoned. The habitual
use of very hot or very cold drinks, more particularly the latter, is
very liable to produce unfavorable results; the deleterious effects of
immoderate amounts of ices, iced-water, and especially of iced-milk,
during the heated term, are clearly established. Idiosyncrasy asserts
itself; ripe strawberries, tomatoes, and other favorite and wholesome.
articles of food, in certain cases not unfrequently produce violent gas-
tric irritation.
Again, acute indigestion is brought on by the use of food which, by
partial decay or bad cooking, has ceased to be wholesome. Tainted
meats, badly brewed beer, unripe or decaying vegetables and fruit, are
sure to create trouble when eaten. Young children are made seriously
ill by being fed upon milk which is sour, or which comes from cows fed
upon medicinal herbs, or upon brewery slops, or from animals which
are forced to habitually drink impure water, All the factors stated
are necessarily modified by hereditary tendency, climate, and expo-
sure to sudden atmospheric changes.
Violent irritation of the gastric mucous membrane is also pro-
duced by the action of certain irritating substances, as alcohol in any
form, or irritating drugs, the latter quite often administered under
618
A SYSTEM OF MEDICINE.
medical advice; the habitual use of alcoholic stimulants, especially,
destroys the integrity of the stomach, and becomes a most important
predisposing and exciting cause of gastric catarrh. The presence in
the stomach of irritant poisons is one of the most common causes
of true acute gastritis, and will be more fully discussed hereafter.
Acute gastric catarrh may occur in connection with certain diseases,
as scarlet fever, measles, variola, erysipelas, cholera, and pyæmia. In
fact, Fenwick (see Quain's Dictionary of Medicine) establishes a connec-
tion between gastritis and eruptive conditions, and divides gastritis
into catarrhal and erythematous.*
Occasionally, acute gastric catarrh is the result of metastasis occur-
ring in gout or acute rheumatism; such a condition always involves
great danger, and is only relieved by the re-establishment of the mor-
bid action in the organs primarily affected.
Morbid Anatomy.-A clear idea of the nature of the anatomical
changes which constitute the lighter forms of gastric catarrh is not
readily obtained; death does not result from them, although gastric
catarrh may have been one of the incidental symptoms of a fatal case;
under such circumstances much circumspection would have to be
used in properly estimating the bearing of the graver malady upon
the structural lesions discovered in the stomach.
The artificial excitation of gastritis in animals, and the observations
of Dr. Beaumont upon Alexis St. Martin, lead to the following con-
clusions: The condition is primarily one of hyperæmia, varying under
different conditions in intensity of action and in extent of territory.
This congestion of the capillary network is most noticeable at the
crests of the inter-glandular prominences, giving to the structure a
pustular appearance. The secreting cells becoming filled with gran-
ular matter and fat globules, the mucous membrane becomes puffed,
somewhat softened, and cloudy in appearance; this swollen condition
of the mucous membrane prevents the discharge into the stomach of
the gastric juices, but the surfaces of the stomach are covered with
ropy mucus of alkaline reaction. Extravasation of blood corpuscles,
both red and white, often takes place. The solitary and lenticular
glands become swollen and, at times, assume such proportion that
they appear like millet seed strewn all over the mucous surface, espe-
cially about the pylorus; the interstitial tissues may become involved,
and ulceration result. Usually the epithelial covering remains intact,
((
* Speaking of erythematous gastritis, Fenwick says: It will be observed that the
morbid appearances, which are strictly analogous to those of the skin in scarlatina,
differ from those produced by catarrh, in the amount of mucus not being increased,
and in the tubes being distended by an albuminous fluid, instead of by an increased
growth of the cells themselves. It is, therefore, analogous to an erythematous affec-
tion of the skin, with which, indeed, it is associated in scarlatina; whilst the catar-
rhal form is analogous to the eczematous and other inflammations of the cutis, which
are characterized by a more abundant formation of the cellular element."
DISEASES OF THE ORGANS OF DIGESTION.
619
but in severe cases it may be destroyed. Erosions are likely to occur,
resulting in superficial ulceration, which may become quite extensive,
and when the case is characterized by unusual intensity of morbid
action, or when the local difficulty is based upon blood-poisoning,
septic or gangrenous inflammations and sloughing may result. The
danger of hæmorrhage occurring in the course of destructive processes
which involve the capillary vessels and deeper-lying tissues, is quite
evident.
The following description of a catarrhal condition of the stomach of
St. Martin is of great interest: "There are sometimes found, in the
internal coat of the stomach, eruptions or deep red pimples, not
numerous, but distributed here and there upon the villous membrane,
rising above the surface of the mucous coat. These are at first sharp-
pointed and red, but frequently become filled with white purulent
matter. At other times, irregularly circumscribed red patches, vary-
ing in size and extent from half an inch to an inch and a half in cir-
cumference, are found on the internal coat. These appear to be the
effect of congestion of the minute blood vessels of the stomach. There
are also seen at times small aphthous crusts in connection with these
red patches. Abrasion of the lining membrane, like the rolling up of
the mucous coat into small shreds or strings, leaving the papillæ bare
for an indefinite space, is not an uncommon appearance. These dis-
eased appearances, when very slight, do not always affect essentially
the gastric apparatus; when considerable, and particularly when there
are corresponding symptoms of disease, as dryness of the mouth,
thirst, accelerated pulse, etc., no gastric juice can be extracted."*
Post-mortem appearances throw little additional light upon the sub-
ject. The hyperæmia which during life forms so prominent a symp-
tom of gastric catarrh, is absent after death, unless the type was one
of unusual severity. It must be remembered that the post-mortem
softness of the tissues, and their liability to tear easily, is the result of
post-mortem disorganization of decay, and bears no relation to that
softening of the mucous membrane during life of which mention has
been made.
Symptomatology.-The first symptoms of an attack of acute
indigestion frequently occur within a few hours after partaking of an
unseasonable, heavy meal, or in the morning following a late and
hearty supper. The first symptoms experienced are usually a feeling
of malaise, of exhaustion, with heaviness in the head, and, especially
in nervous persons, with dryness and heat of the hands; in short,
a feeling of general indisposition. A more or less severe headache
develops, generally frontal, possibly with slight visual disturbances.
A sensation of discomfort at the stomach is experienced, with loathing
of food, nausea, and vomiting.
* Beaumont Experiments and Observations, etc., on Alexis St. Martin, page 99.
620
A SYSTEM OF MEDICINE.
The matter ejected usually consists of a watery substance, mixed
with food in a state of partial fermentation and, if the vomiting be
continued for any length of time, with bilious matter. The ejection of
the offending substances may end the trouble, the symptoms gradually
and quickly disappearing, and a few hours' rest being sufficient to the
restoration of health. If the offending substance is not removed, but
passes out of the stomach into the intestines, or if the case be one of
some severity, the intestinal canal partakes of the disturbance. If
a diarrhoea sets in, the headache, nausea, and other symptoms de-
scribed, usually grow lighter after a time, while pains in the bowels,
with frequent watery, bilious, and often offensive, stools continue for
some time, gradually lessening in frequency, and finally disappearing,
with a rapid recovery of health. In case the bowels become consti-
pated, the gastric irritation becomes more pronounced. Vomiting
continues, the tongue is covered with a heavy white or yellowish or
brown fur; the breath becomes offensive; the headache increases in
severity, locating itself in the frontal, less frequently in the occipital,
region; the pulse is disturbed, showing an appreciable softness and
irregularity rather than an increased rate of the beat per minute.
The feeling of malaise becomes intolerable; nervous symptoms appear,
the patient showing marked sensitiveness to light and noise, demand-
ing perfect quiet, and vigorously protesting against all disturbance;
there is shuddering, yawning, and stretching; the sickness at the
stomach becomes almost continuous, while vomiting aggravates the
headache, without generally giving marked relief to other symptoms.
The patient feels drowsy, and vainly seeks sleep, in the hope of finding
in sleep relief from his suffering. Thirst rarely exists at this stage.
Sleep finally comes and is usually profound, the patient awakening
much rested and improved in every respect, but suffering from a feel-
ing of exhaustion which is quite marked in view of the short time he
has been sick.
The headache, in the course of these brief but violent attacks of in-
digestion, forms a very conspicuous and painful symptom, so much
so that the people have given to this type of acute indigestion the
name of "sick headache."
At times, recovery from these attacks is protracted beyond the
length indicated here, and the morbid symptoms yield only reluc-
tantly. The loathing of food, and the uneasiness and pain at the stom-
ach, the latter of a heavy, dull character, continue; there is marked
indisposition to exertion; great languor; heaviness of the head; a
bad, often metallic, taste in the mouth; heavily furred tongue; eruc-
tations of sour, at times intensely acrid, watery substances; food tastes.
insipid; the patient often complains of thirst, and suffers from an an-
noying, gnawing feeling, with faintness at the stomach; he has eruc-
tations of gas, bearing the odor of sulphuretted hydrogen; there is a
DISEASES OF THE ORGANS OF DIGESTION.
621
tendency to salivation and heart-burn; the urine is scanty, high-col-
ored, acid, and contains lithates. The bowels are confined, or, if loose,
a watery, offensive diarrhoea exists, accompanied with considerable
griping. There are shiverings, heavy unrefreshing sleep, disturbed by
anxious dreams, soreness of the lips and corners of the mouth, and,
at times, herpes and urticaria. This condition, the status gastricus of
older writers, wears away in the course of a few days, or assumes, in
rather exceptional cases, the form of a chronic affection.
The subacute gastritis of some writers, called gastric fever by others, is
a form of gastric catarrh rather more severe than the condition de-
scribed. The mere shiverings become more clearly defined rigors; the
temperature rises several degrees above normal, usually not to exceed
100° F., save in children, where the thermometer may mark 103° F.;
the pulse is weak and compressible, and there are distinct evening
exacerbations of the fever. There is pain in the epigastric region,
radiating into the chest, back, and hypochondria, although many cases.
are characterized by a notable absence of pain. Anorexia usually ex-
ists, though some patients experience a recurring craving for food.
Thirst becomes a marked symptom, but the stomach is too irritable
to retain either drink or food, and their introduction then produces
an aggravation. Vomiting continues, of glairy mucus mixed with.
water, food, bile, and small amounts of blood; it is painful, and readily
brought on by eating, but more especially by drinking water. The
tongue preserves its characteristic coating, at first heavy, white, dirty,
later becoming red, glaring, raw, and even fissured, with conspicu-
ously large, red papillæ; the lips are parched and cracked. The
bowels may be constipated or loose. The prostration is quite marked,
the headache is constant and severe; sleep is restless, unrefreshing.
There is present a considerable degree of nervous excitement, which
is most marked in children and in nervous people. Frequent eructa-
tions of foul gas and flatulence of the bowels become a source of con-
siderable annoyance, and are accompanied by dizziness and, probably,
by irregularity in the action of the heart. In somewhat rare cases
there may be observed dysphagia and partial aphonia. There is no
marked tenderness to pressure in the epigastric region, and a hacking
cough is occasionally observed; the latter must be watched closely,
the physician bearing in mind the similarity existing between this
condition and certain cases of phthisis in the earlier stages.
This state of affairs is likely to run for a period of from six to ten
days; the prognosis is decidedly favorable, but a chronic irritation
may remain, to be removed only by skillful and persevering medical
treatment.
Gastritis proper is rarely found as an idiopathic disease, but is of
not unfrequent occurrence as the result of the action of some irritant
poison upon the stomach. Its symptoms are all of great intensity.
622
A SYSTEM OF MEDICINE.
The mucous lining of the stomach and the underlying structures are
violently inflamed. The pain at the stomach is very acute and sharp,
often excruciating; pressure cannot be borne, even the pressure of the
descending diaphragm during the respiratory movements is so painful
that the breathing soon becomes superficial. Constant painful vomit-
ing of glairy, stringy mucus, probably mixed with blood, is a very
common symptom, and the stomach is so irritable that every attempt.
to eat or drink is followed by violent retching and vomiting. Thirst
for cold drinks is intense, and indulgence is invariably followed by
renewed vomiting; nevertheless, the patient cannot resist the craving
for water, and drinks in spite of the consequences. Diarrhoea sets in
soon, with colic, violent tenesmus, bloody, watery stools, and other
symptoms showing that the intestinal lining membrane is becoming
extensively involved in the inflammatory action. The tongue becomes
dry and glazed; the countenance assumes a pinched look, expressive
of the keen suffering and of the profound prostration of the entire
system, which is becoming more and more marked; there is difficulty
of swallowing and of articulation; the pulse is increasing in rapidity
and lightness; the urinary secretion becomes scanty, and is often sup-
pressed; hiccough sets in; the vomited matter appears black, like
coffee-grounds; active hæmorrhage may take place, and death results
from collapse.
If a fatal termination is averted, the stomach rarely recovers fully,
and structural changes, as cicatrices from ulceration, are very likely
to remain, producing characteristic and serious disturbances.
A very grave form of gastric catarrh occurs among young infants,
more frequently among those fed artificially, and during the heated
term. Its causes, in an overwhelming majority of cases, are found in
bad feeding. The gastric symptoms are generally well marked. There
is frequent, at times almost constant, vomiting of milk which is usually
ejected in curdles or in solid lumps, or of very sour, watery substance
mixed with milk; the stomach is exceedingly irritable, and refuses to
retain nourishment or drink, the latter being eagerly called for by the
little patient; the vomiting is often preceded by manifestations of se-
vere pain in the stomach; the abdomen is hot and frequently, though
not always, tender to pressure; the face and extremities are blue and
cold; diarrhoea accompanies the gastric irritation; the stools are very
frequent, varying in color, but being of watery consistency, and often
remarkably copious and exhausting; emaciation and prostration take
place rapidly; the face becomes pinched, the eyes lustreless, the fon-
tanelles depressed, the pulse indistinct, and the urine scanty; brain-
symptoms develop with coma, convulsions, and death.
Gastric catarrh which depends upon the excessive use of alcohol is
characterized by profound anorexia, a habitually and heavily coated
tongue, and persistent thirst. There is very little sensitiveness to
DISEASES OF THE ORGANS OF DIGESTION.
623
pressure. The condition depends chiefly upon the mechanical action
of the alcohol upon the gastric mucous membrane.
Gastric catarrh occurring in connection with other diseases rarely
presents violent symptoms, and may disappear with the cure of the
disease upon which it depends. Whenever gastric disturbances occur
during the existence of gout or of acute rheumatism, they are to be
regarded with suspicion, and must receive the close attention of the
attending physician. Should metastasis of the disease to the stomach.
take place, the case at once becomes alarming, and does not cease to
remain so until the inflammatory action in the joints has been reës-
tablished, when the symptoms of gastric catarrh will rapidly dis-
appear.
Diagnosis. Usually, the symptoms of acute gastric catarrh are
sufficiently pronounced to make a correct diagnosis a matter of com-
parative ease to the intelligent medical observer. The peculiar intol-
erance of the stomach, the character of the vomiting, the appearance
of the tongue, the absence of a continuously high temperature, and,
in many instances, the ability to find a specific cause for the attack,
are reliable diagnostic symptoms.
The lighter forms of gastric catarrh occurring in the course of other
diseases, more especially in connection with diseases of the lungs, are
not always promptly recognized. It is, therefore, well to exercise con-
siderable care in watching the totality of symptoms, and, in certain.
cases, to subject the lungs to a thorough examination. The presence
or absence of physical signs referring to the lung will nearly always
determine the nature of the difficulty, particularly with careful atten-
tion to the coating of the tongue and to the temperature of the body.
A differential diagnosis between the severer forms of acute gastric
catarrh with a pronounced feverish condition-i. e., the so-called gastric
fever of some writers-and the earlier stages of typhoid fever or of
peritonitis may present serious difficulties. In fact, it is not unfre-
quently impossible to arrive at a positive diagnosis until a sufficient
time has elapsed to develop the pathognomonic symptoms of the latter
diseases. The diagnosis of typhoid fever depends upon the existence
of a more continuously high temperature, of the characteristic ileo-
cæcal tenderness to pressure and gurgling, splenic enlargement, and
the appearance of the characteristic eruption. Attention is also called,
by some authors, to an herpetic eruption which often accompanies.
gastric disorders, and which is absent in typhoid fever. Peritonitis,
particularly those cases in which vomiting is an established feature, is
not so easily distinguished, and the physician, in differentiating, must
largely rely upon the diffused abdominal tenderness and the tympa-
nitis, none of which belong to the symptomatology of gastric catarrh.
Cardialgia or gastralgia may be taken for gastric catarrh. The
paroxysmal character of the pain, the absence of excessive gastric irri-
624
A SYSTEM OF MEDICINE.
tability, the ability to retain food, and the absence, usually, of tender-
ness in the gastric region, determine in favor of the former.
For evident reasons, it may become necessary, in a case of true gas-
tritis, to determine if the disease is idiopathic or is caused by the in-
troduction, accidental or deliberate, of an irritant poison. In cases of
self-poisoning a motive for the act is likely to exist, and careful in-
quiry with reference to the motive must be made; in case of attempted
murder by poisoning the patient is not usually able to render thist
assistance. The suddenness of the attack, the remarkable severity of
the symptoms, and the early vomiting of blood found here, are rarely
had in the idiopathic cases. Careful examination must be made of
the lips, tongue, buccal cavity, and fauces, as irritant poisons, in their
momentary retention in the mouth preparatory to the act of swallow-
ing, are quite sure to leave their traces upon the superficial structure
of the mouth.
Prognosis. The prognosis is decidedly favorable in the lighter
forms of gastric catarrh; it is doubtful in true gastritis, in cases of
poisoning depending almost entirely upon the amount of local destruc-
tion done by the irritant action of the poison. Death, in gastritis.
toxica, is usually directly due to the shock sustained.
Treatment.-Careful attention to diet constitutes an important
part of the treatment of acute gastric catarrh. The beneficent effect of
physiological rest of the organ is becoming more and more understood
by the profession, and abstinence from food, within limits of prudence,
is being generally practiced in the treatment of this disease. By thus
giving rest to the irritated or inflamed organ, many light cases make
a prompt recovery without other treatment. It is evident that reason-
able care and judgment must be exercised by the physician in deter-
mining the length of time for which the patient may be deprived of
food with safety and advantage to himself. Usually speaking, the
return of tolerance of food by the stomach is an indication that it may
be given with safety in moderate amount. In many cases of consider-
able severity it is well to insist upon perfect rest of the stomach for a
period of twenty-four, or even forty-eight, hours, allowing the patient
to take small bits of ice to allay the dryness of the mouth and the
active thirst which usually exist. When the fast is broken, consider-
able care must be exercised in the proper selection of food. It is
advisable, at first, to restrict the diet to milk and lime-water, given in
small amounts every two or three hours; milk and soda-water may
be used in the same way. Later, barley-water, gruel, arrow-root, or
sago may be administered, to be followed, as the patient improves, by
chicken-broth, beef-tea, or mutton-broth. A return to solid animal
food must always be made with the greatest of care, and should never
be permitted until every symptom of nausea and of pain at the
stomach, particularly after eating, has disappeared. Even then, it is
DISEASES OF THE ORGANS OF DIGESTION.
625
the part of wisdom to commence with the lighter meats, such as fish,
oysters, young chickens, and game. The slightest disturbance of
digestion should be considered a danger-signal, and rouse the physi-
cian to extreme vigilance. Vegetables and fruit must be used with
great caution, and malt liquors, tea, and coffee should usually be
absolutely forbidden.
As a general thing, it is well to bear in mind that cold foods are
most refreshing, and seem to be borne well by the stomach; in some
cases ice-cream is borne well, and small drinks of cold milk are not
unfrequently very grateful to the patient.
In protracted cases, with great irritability of the stomach and much
exhaustion, recourse to rectal alimentation may become a necessity.
Before giving the enema, the rectum must be carefully and thoroughly
washed by an injection of clean warm water; the injection itself must.
be given slowly, thrown up high into the rectum, should not exceed
in amount half a teacupful at a time, and should be repeated at inter-
vals of from two to three hours. The temperature of the enema must
correspond to that of the blood. Warm milk or beef-tea, to which
both Pepsin and Muriatic acid should be added, and defibrinated
blood, meet the requirements. The value of beef-tea depending
largely upon its proper preparation, the following rules, formulated by
Dr. Charles Gatchell, will be found of service: Never let beef-tea boil;
always begin preparations for making it with cold water. The finer
the beef is cut, the better. There should be no fat, gristle, or bones
adhering to the meat. The proper proportion of beef to water is a
pound to a pint. Beef-tea that "jellies" when cold has not been
properly made. After being made, carefully remove from the surface
all traces of fat. To " warm up" beef-tea, put it in a cup and set the
cup in a vessel of boiling water.
The following recipes, from the same source, are of great value:
"Take one pound of fresh meat, cut very fine; soak in one-third of a
quart of cold water overnight. In the morning remove the meat,
saving the water in which it is soaked; put the meat into two-thirds
of a quart of water, and let it simmer for two hours, keeping the water
up to its original level by replacing what is lost by evaporation; now
pour the beef broth into the cold liquor in which the meat was soaked,
squeezing the meat as dry as possible. The meat which remains
should be spread on a tin plate and slowly dried in an open oven;
when perfectly dry, it can be easily reduced to a powder in a mortar;
mix this meat powder in the liquor, and you have all the elements of
the meat in a fluid form. Salt to taste, and add 20 drops of Muriatic
acid and 3 grains of Pepsin. Or:
“Prepare a pound of beef in the usual manner, and soak it in a pint
of cold water for two hours; now place the vessel containing the meat
in a saucepan of water, and let the water in the latter boil for three
VOL. I.-40
626
A SYSTEM OF MEDICINE.
hours. Putting the meat and water into a stone bottle, and this into
a kettle of boiling water, answers the same purpose. Replace water
that is lost by evaporation. When done, strain and salt to taste. The
last vestige of fat may be removed by skimming the surface with a
piece of white blotting-paper."
If the pain and the tenderness in the epigastric region are very
marked, the application of poultices of linseed-meal or of hot fomen-
tations is advisable. If vomiting perseveres, tending to produce great
exhaustion, or if it occurs as the result of exhaustion, stimulants,
cautiously used, may afford relief. Iced champagne not unfrequently
acts like a charm in such cases, and small pieces of ice, frequently
given, or small amounts of Vichy or Seltzer, act both as a sedative
and antacid. The dominant school, in such cases, have been in the
habit of employing Opium with satisfactory results; indeed, not
unfrequently the administration of an opiate appears both excusable
and effective. Better results, however, may be obtained by the use of
warm water. Dr. A. N. Pennoyer, of Kenosha, Wisconsin, in all
cases of acute indigestion strongly recommends the administration of
a half cupful, or more, of water as hot as it can be borne. If relief is
not had, he gives warm water until free vomiting occurs, repeating
the operation two or three times, even after free emesis has taken.
place. The patient is likely to protest after having taken two or three
glasses, but may be persuaded by the promise of prompt relief to
repeat the doses. From twelve to thirteen glasses of lukewarm water.
may thus be given, and copious injections of water be made into the
bowels. The writer has found this treatment of acute cases of indiges-
tion eminently satisfactory. The removal of the offending substance
from the stomach is thus effected easily, and without that temporary
marked aggravation which is likely to result from the employment of
emetics.
The use of stimulants involves many objectionable features, and is
entirely out of the question save in cases where prostration is extreme.
As already stated, champagne has peculiar advantages; if champagne
is not available, small doses of brandy should be given to the exclu-
sion of all other stimulants.
The necessity of the most careful attention to diet in cases of acute
indigestion which occur in young infants is quite apparent. The health
of the nurse, and, in case cow's milk is fed, the health of the animal, the
care which it receives, her feed and drink, the condition of the stable,
all these should receive careful attention. Children brought up by
hand necessarily suffer much from disorders of digestion, and too
much attention cannot be given to the source of supply of the milk
used. Very often, particularly during the hot summer months, the
admixture to the milk of Lime-water or of Carbonate of soda is of
much value. Cases often occur, however, where milk cannot be borne.
DISEASES OF THE ORGANS OF DIGESTION.
627
under any circumstances; in such cases the use of oatmeal gruel,
diluted at first with water, and later with the purest milk obtainable,
proves a satisfactory diet. The value of certain artificial foods is gen-
erally recognized, and, in cities, condensed milk of a reliable brand is
an easily prepared and valuable food for children.
During convalescence from a severe attack of gastric catarrh, pure
Pepsin may be used advantageously.
Therapeutics.—Arsenicum.-Nausea and vomiting; worse from rising; burn-
ing pains in the stomach and abdomen, with pale or even hippocratic face and cold
extremities; dry skin, either hot or cold; quick, light pulse; tongue dry and red, or
sides furred, with red streaks down the middle; redness of the lips; characteristic
thirst; anxious restlessness; quick prostration; watery or dark-brown diarrhoea,
sometimes with blood; excellent remedy after the abuse of ice, ice-cream, ice-water,
sour beer, vinegar; also in persons suffering from the effects of excessive chewing
of tobacco.
Bryonia.-Stitching pain in the stomach, worse from motion, particularly from
jarring; tongue coated whitish or dark yellowish brown; lips and mouth dry, but no
thirst, or constant drinking, day and night, of large amounts; constipation of dry,
burnt stools; of particular service during hot weather, when symptoms occur from
taking cold drink when heated, and after the use of flatulent food.
Nux -Sour or bitter taste in the month; tongue heavily coated, white or yellow;
fulness and dull heavy pressure in the stomach; dizziness, with severe frontal head-
ache and irritability of temper; the symptoms worse in the morning, in the open air,
after eating.
Aconite. After taking cold; stitch-like, burning, pressing pain at the pit of the
stomach, with anguish and fear of death; dry, quick, hard pulse, with heat of the
flesh, and constant, restless tumblings about in bed; fever, with great thirst and vom-
iting. Of particular value when the muscular coat of the stomach is involved.
Iris vers.—Intolerable burning distress at the stomach; colicky pains for a
few minutes in the epigastrium; shocks of pain radiating from the umbilical region
into the epigastrium; nausea, straining, belching of wind; vomiting of mucus and bile,
with diarrhoea, accompanied with burning in the anus and great prostration; burning
in the mouth, fauces, and oesophagus; sick headache
Podophyllum.-Everything in the stomach turns sour; Lelching of sour, hot
flatus, with great thirst and vomiting, preceded by distressing nausea, and accompanied
with such violent contractions of the stomach during vomiting that the patient screams
with pain; vomiting of bilious matter, mucus, with blood; the tongue is furred, white,
dry, yellow; foul taste in the mouth.
Pulsatilla.—No appetite; no thirst; tongue coated white or yellow, with tena-
cious mucus; edges feel sore as if scalded; mouth parched and dry, but patient calls
for no water; everything tastes bitter, and there is a bitter taste in the mouth; dizzi-
ness when rising from a chair; chilliness; stitching pain in the stomach; worse from
walking, and from a jar; perceptible pulsation in the pit of the stomach; pain in the
stomach during inspiration and from pressure; tension from stomach to the chest ;
attack brought on from the injudicious use of ice-cream and fruit, rich pastry.
Hydrastis.-Dull, aching pain in the stomach, causing epigastric weakness and
faintness; tongue coated white or with a yellow stripe; feels as if burnt or scalded;
a vesicle forms on the tip of the tongue which is very sore; acidity; constipation.
Phosphorus.-Acute, burning pain in the pit of the stomach; soreness in the
gastric region; shuddering; cramp in the stomach, radiating from the liver; vomit-
ing of watery substances, at times with the admixture of blood; great thirst for cold
water, which is ejected as soon as it gets warm in the stomach; weakness of react-
ing power; tongue dry, or coated white.
Chelidonium.-Tearing, darting, throbbing pains in the forehead and temples,
with heaviness and coldness in the occiput, accompanied with vertigo, anxiety, mel-
ancholy, nausea, and bilious vomiting; the tongue is slimy, coated white or gray;
heavy yellow coat to the tongue, with red margins, showing impression of the teeth.
Useful when of hepatic origin.
Belladonna.-Acute pain in the stomach, worse from motion or pressure;
628
A SYSTEM OF MEDICINE.
pressive pain extending to chest and shoulders; the pit of the stomach is swollen, with
tension in the abdomen, across and below the umbilicus, worse from motion and pres-
sure; deficient breathing, anguish, vomiting, gagging, hiccoughing; great thirst, but
the patient dare not drink, because drinking aggravates all the symptoms; sleepless-
ness; tongue is covered with tenacious, yellow-white mucus, or is dry and furred;
congestive type.
Antimon, crud.-Total loss of appetite; tongue coated thickly, yellow or
white; great thirst at night; nausea; belching, with taste of the food that has been
eaten; vomiting; no fever; indicated in saburral derangements, after the use of bad,
sour wine.
Veratrum alb.-Violent vomiting, with continuous nausea and prostration ;
the pains radiate from the stomach upwards and to both sides, to the back between the
lowest points of the scapula; it becomes agonizing, and then gradually subsides; an-
guish in the pit of the stomach, with cold extremities; hippocratic face; slow pulse,
coldness, and fainting fits; cold sweat and nausea, brought on by the slightest motion;
hæmatemesis; tongue cold, covered white, with red tip and edges, or coated yellowish-
brown.
Ipecacuanha.-Constant nausea from the stomach; easy vomiting; empty
eructations, and copious accumulation of saliva; the pain most severe in the anterior
abdomen, extending to the left hypochondrium, sides, back, base of the chest, with
great bloating of the stomach, and agitation; headache as if the skull were bruised;
diarrhoea; tongue clean, yellow or white, flabby, after eating sour things, especially
sour and unripe fruit.
Sanguinaria.-Nausea, with headache, chill and heat; vomiting with severe
painful burning in the stomach and intense thirst; red tongue; red dry lips; hot dry
throat; tickling cough.
Euphorbia cor.-Sudden nausea, vomiting, and diarrhoea of watery fluids,
with sinking, anxious feeling in the stomach; faintness, slow and weak pulse; cold
skin; cold feet and hands; cold sweat on body and extremities; spasms of the legs
and feet from fright, over-indulgence in ices, fruits, etc. (Jahr.).
Consult also: Apis, Carbo veg., Arnica, Cantharides, Mercury, Rhus
tox., China, Chamomilla, Sepia, Hyoscyamus, Kali carb., Rumex
crisp., Laurocerasus.
GASTRITIS TOXICA.
Synonyms. Gastritis caustica, Inflammation of the stomach from
poisoning.
A consideration of this subject properly belongs to special works on
toxicology, but the convenience of the general practitioner may be
served by a few remarks upon the subject in this place.
Of the different classes of poisons only the corrosives and the irri-
tants have a marked effect upon the gastric structures; the neurotics
affect the stomach only incidentally, and kill by their action on the
great nerve-centres. The action of the irritant and of the corrosive.
poisons resembles each other, the latter being the more violent of the
two. They act primarily upon the mucous membrane with which
they are brought into direct contact, changing the consistency and
color, and destroying the lining of the mouth, fauces, oesophagus and
stomach. The inflammation thus produced, especially of the stomach,
where they find a resting-place, is intense, resulting in ulceration and
perforation, the edges of the perforation being ragged, torn, shreddy.
The mineral acids, more especially sulphuric acid, are exceedingly
violent in their action, and in the case of the latter the structures are
DISEASES OF THE ORGANS OF DIGESTION.
629
changed into a blackish mass from the action of the acid upon the
blood-pigment. Other acids, when taken in a diluted form, have a
similar, but less violent, effect, changing the superficial layers into a
soft, pulpy, brownish mass. The caustic alkalies act with exceeding
violence, even more so than the larger number of acids. The intestines,
more particularly the small intestines, usually escape the destructive
action of these poisons; the mercurial salts, however, not unfrequently
exert a violent effect upon the large intestine, and particles of the
poison are in some cases detected in the intestinal tract, a fact
which may serve to identify the poison taken.
The symptoms of poisoning differ greatly; those poisons which act
through the great nerve-centres produce disturbances unmistakably
pointing in that direction. Space cannot be given to their considera-
tion. The irritant and corrosive poisons all produce sudden and vio-
lent gastric and intestinal disturbance, with intense pain in the stomach
and bowels; frequent, and often excessively painful, vomiting, soon.
showing admixtures of blood; diarrhoeic discharges from the bowels,
accompanied with great tenesmus, containing, like the ejections from
the stomach, threads of membrane and bloody masses; great depres-
sion shows itself; the extremities become cold; the surface of the
body is bathed in profuse, clammy, cold perspiration; the countenance
is distorted, haggard, hippocratic; the pulse small, threadlike and im-
perceptible, and death soon results from shock.
The prompt recognition of the particular poison taken often presents
much difficulty; the acids and alkalies, by their action upon the
mucous membrane of the mouth and fauces, can usually be recog-
nized; the character of other substances can be ascertained only by a
careful chemical and microscopical examination of the vomited matter
and stools. Usually, the patient, in case of accidental poisoning, or
even when suicide has been attempted, is anxious to give the
needed information, thus enabling the physician to take immediate
and pointed measures to secure the recovery and comfort of the
sufferer.
The Prognosis depends largely upon the nature of the poison swal.
lowed, upon the amount taken, the promptness with which medical aid
is summoned, and the efficiency of the physician in charge.
Treatment.-Removal from the stomach of the noxious matter
taken is the first duty which requires the physician's attention. If the
practitioner holds himself in particular readiness to answer such calls,
he is armed with the various instruments, apparatus and preparations
the use of which may be demanded. In general practice, and espe-
cially in country practice, such liberal preparations are not had, and
the physician must often depend upon means most readily obtained.
It is then best to evacuate the stomach by the use of any emetic that
can be had at once; mustard-water, for instance, made by adding a
•
630
A SYSTEM OF MEDICINE.
tablespoonful of mustard to a half-pint of warm water, or a solution
of common salt, two tablespoonfuls in a half-pint of tepid water, can
usually be procured immediately; copious draughts of tepid water,
with a free admixture of grease, usually produce prompt results. A
stomach-pump may be extemporized by passing through the œso-
phagus into the stomach the end of a long rubber tube; if the free end
is raised above the patient's head, water may be poured into the
stomach through a small funnel attached to the tube; the stomach
filled, it can readily be emptied by lowering the free end of the tube
below the level of the stomach. This simple process repeated, a com-
plete emptying and rinsing-out of the stomach can be had.
Poisoning by acids requires lime-water, chalk, magnesia or ashes.
Poisoning by alkalies demands acids. Narcotics require stimulation,
strong coffee, inhalations of Nitrite of amyl, brandy, whiskey, flagella-
tion. Belladonna antidotes Opium. Dialyzed iron, in large doses, fre-
quently repeated, is an excellent antidote for Arsenic; and Chloral,
Chloroform, and the administration of animal charcoal and Tannic
acid, in large amounts, are to be used in poisoning with Strychnine.
Of the emetics commonly employed, Sulphate of zinc is given in
thirty-grain doses, Ipecacuanha in twenty-grain doses; Apomorphia
acts very promptly, and is an invaluable agent in such cases; from
one-tenth to one-fourth of a grain may be given by the mouth or hypo-
dermically. Salt and mustard may be used as already indicated.
Tartar emetic should be administered in doses of three grains in water;
it is, however, undesirable to employ this drug to any extent, as it pro-
duces violent nausea and vomiting, and seriously depresses the entire
organism.
The following list of poisons and their antidotes may be found of
service:
Acid. acet.-Soap and water. Lime-water. Chalk-water. White-wash and
water. Magnesia. Milk. Oil. Thick gruel. Morphia. Use no stomach-pump.
Acid. arsen.-See Arsenic.
Acid. carbol.-Emetic. Stomach-pump. Wash out the stomach with soda or
saccharated lime, dissolved in large quantities of hot water, until the water returned
gives no longer the odor of carbolic acid. White of egg, freely. One ounce of Castor
oil, or three ounces of Olive oil. Stimulate freely by applying heat to the extremities,
friction on the surface of the body, the interrupted current, and inhalations of Amyl
nitrite. Use, if necessary, one-sixtieth of a grain of Atropia, hypodermically.
Acid. carbon.-Fresh air; windows and doors wide open. Cold applications
to the head. Cold douche. Stimulants. Ammonia to the nostrils. Galvanism. Fric-
tion and warmth to the extremities. Hot coffee per rectum. If oxygen can be had,
give it by inhalation. Artificial respiration must be employed untiringly. Use ca-
theter if depression is profound and long-continued.
Acid. citric.-See Acetic acid.
Acid. hydrochlor.-Give immediately large draughts of soap and water; bi-
carbon. of potash or of soda. Ammonia or common washing-soda, well diluted with
water, may be given. Magnesia or lime-water. Milk. Oil. White of egg in water.
Gum and water. Linseed tea. Morphia hypodermically. Do not use stomach-pump.
Acid. hydrocyan.-Requires immediate and vigorous attention. Stomach-
pump or prompt emetics. Stimulate freely with brandy, Ammonia, Chloric ether. If
DISEASES OF THE ORGANS OF DIGESTION.
631
swallowing is impossible, use diluted brandy, per rectum or hypodermically. Inhala-
tions of Ammonia on a pocket handkerchief, to be used with caution. Hot and cold
douche. Pour water from a height over the head and chest. Hypodermic injection
of one-sixtieth of a grain of Atropia; or thirty drops of tincture of Belladonna, by the
mouth. Mild interrupted current over the chest and region of the heart. Friction on
the chest. Artificial respiration to be kept up persistently.
Acid. mur.-Carbonate of lime (chalk or whiting) to be used freely. Magnesia,
soda, etc., in milk or in some mucilaginous drink.
Acid. nitr.-Treatment same as in Hydrochloric acid.
Acid. oxalic.-Same as treatment by other acids, only the alkaline carbonates
should not be given.
Acid. sulphur.-Same as in Muriatic acid.
Acid. tartar.-Chalk. Whiting. Magnesia. Soda. Mucilaginous drinks. Lin-
seed tea. Linseed oil, etc. Morphia, hypodermically. Stimulants, if necessary.
Aconite.-Half a fluid drachm of spirits of Camphor in a teacupful of hot water,
to be given at once. Emetic. Stomach-pump. Warmth at extremities. Mustard leaf
over the heart. Use tincture of Digitalis, twenty drops, hypodermically. Nitrite of
amyl, by inhalation. Stimulants by mouth and rectum. One-sixtieth of a grain of
Atropia, or twenty drops of tincture of Belladonna by mouth or rectum. If the pulse
does not improve, repeat the latter. Keep the patient in a recumbent position, and
maintain artificial respiration for no less than two hours, if necessary.
Alcohol.-Give at once active emetic. Warm mustard water or Sulphate of zinc;
of the latter, fifteen to twenty grains. Cold douche to the head. Warm flannels and
friction to the extremities, if cold. If the case is severe, use Ammonia, Digitalis, Caf-
feine, hypodermically.
Alkalies.---In poisoning with the alkalies, or any of their salts, as Ammonia,
Potassa, Soda, employ, if called at once, the different vegetable acids, as vinegar, lemon-
juice, freely diluted with water, or weak solutions of Citric and Tartaric acid. If some
time has elapsed, use Oil of almonds, Linseed oil, Castor oil, and lard; later, wash out
the stomach with warm water. Mucilaginous drinks. Nutriment per rectum. Stimu-
late, if necessary. If cedema of the glottis exists, the performance of tracheotomy may
be imperative.
Amyl nitrite. -Evacuate the stomach promptly with active emetics or stomach-
pump. Give an abundance of fresh air, and keep up, with all due perseverance, arti-
ficial respiration. The patient must be kept in the recumbent position.
Antimony, salts of.-Freely administer decoction of white oak bark, or Tannic
or Gallic acid in any form. Milk. Carbonate or calcined magnesia in milk. Vomit
the patient.
Arsenic.—Emetics are rarely needed; if used, follow by large draughts of hot water
and salt, to wash out stomach. Hydrated peroxide of iron, fresh, from half ounce to
an ounce, every ten minutes until better. Dialyzed iron in one-ounce doses repeatedly.
If iron not at hand, give magnesia in unlimited quantities. Stimulants, if needed.
Mucilaginous and albuminous drinks, as white of egg, linseed tea, and so forth.
Warmth; hot blankets; hot bottles to feet; friction to extremities. Morphia, if neces-
sary. When the more acute symptoms have subsided, use linseed poultices to the ab-
domen, and one-eighth to one-quarter grain of Morphine, hypodermically, if neces-
sary.
Arsenious salts.-Same as Arsenic.
Atropia.-Stomach-pump, or emetic of mustard water, sulphate of zinc, or ipe-
cacuanha; also, stimulants. Coffee; enema of one pint of hot, strong coffee. Mustard
to calves of legs. Hot-water bottles to feet. Flagellation with wet towel. Hot and
cold douche. Interrupted current to limbs. Pilocarpine nitrite (solution of one part
in twenty) ten minims hypodermically. Repeat, if necessary, or two drachms of the
tincture of Jaborandi by the mouth or rectum. Artificial respiration for two hours, if
necessary.
Baryta (carbonate, chloride, nitrite).-Sulphate of soda or magnesia. Phosphate
of soda. Fixed oils.
Belladonna.-Same as Atropia.
Bismuth.—Milk. Mucilaginous drinks. Emetics. Stomach-pump.
Camphor,—Emetics, Stomach-pump. Stimulants, to be used freely. Warmth.
632
A SYSTEM OF MEDICINE.
Hot blankets. Hot-water bottles. Friction. Electricity. Hot and cold douche to
head and chest.
Cantharides.-Mucilaginous drinks. Copious draughts of milk. Camphor-
water. Later, emetics. Stomach-pump. Morphia, if needed.
Fric-
Chloral hydrate.-Strong coffee. Hot bath or pack. Hot blankets.
tion. Stimulants. Ammonia. Caffeine. Strychnine, hypodermically; nitrate of
strychnia; solution of strychnia (one part in fifty), two minims, hypodermically. Stom-
ach-pump. Artificial respiration. Electricity. Hot coffee per rectum. Tincture of
Nux vomica, mouth or rectum. Amyl nitrite.
Chlorine.-Sulphide of ammonia. Inhalations of aqua ammonia, to be given
cautiously. Artificial respiration.
Chloroform.-If inhaled: Give an abundance of fresh air. Pull the tongue
forward. Clear the mouth. Unfasten the clothing. Place head very low. Alternate
cold and hot douche. Amyl nitrite. Ammonia. Electricity, placing one pole on the
pit of the stomach, the other on the larynx; to be used for a short time only and very
cautiously. Artificial respiration, about eighteen per minute. In apparently hope-
less cases, two or three violent blows on the chest, delivered in rapid succession, may
restore action of the heart.
If swallowed: Emetics Stomach-pump. Large draughts of water, containing car-
bonate of soda in solution. Rouse the patient by all means. Employ flagellation.
Mustard to the calves of the legs and over the heart.
Coal gas.-Fresh air in abundance. Artificial respiration kept up steadily
and for a very long time. Ammonia to the nostrils. Friction to the extremities.
Mustard to calves of legs and over the heart. Interrupted current to the extremities.
Stimulants by the mouth or rectum. Enema of a pint of hot, strong coffee. Cold and
warm douche to the head and chest. If oxygen is obtainable, inhalations of it may
be employed to advantage. Bleeding is often indicated, and in very prolonged cases
the catheter must be used.
Copper, salts of.-Milk. White of egg. Sulphide of iron; magnesia; sul-
phate of soda. Barley water. Gruel. Arrow-root. Mustard-water or ipecacuanha, to pro-
duce emesis, if necessary. One-half grain of morphia, hypodermically, or twenty-five drops
of laudanum by the mouth. Linseed poultices to the abdomen. Avoid all acid drinks.
Corrosive sublimate.-See Mercury.
Croton oil.-Stomach-pump. Mustard-water. Sulphate of zinc. Ipecacuanha
for emesis. Use demulcent drinks frequently, as barley-water, white of egg and water,
gruel, arrow-root. Use stimulants freely-brandy, sal vol., chlor. ether. Linseed-
meal poultices to abdomen. One-third to one-half grain morphia, hypodermically.
Twenty minims of laudanum by the mouth, repeated in an hour, if necessary.
Digitalis.-Stomach-pump. Emetics. Twenty grains of tannic acid or gallic
acid, in hot water, given frequently; strong hot tea or coffee. Stimulants per rectum,
if not retained by the stomach. One one-hundred-and-twentieth (ro) grain of Aco-
nite (two minims of a solution of one to 240), hypodermically, or six minims of Tinct-
ure of aconite by mouth or rectum; to be repeated in a half hour, if heart's action is
not perceptibly improved. The recumbent position must be strictly maintained, even
for a long time after all the symptoms have subsided.
Ergot.-Stomach-pump or emetics. Active purgative. Tannic or gallic acid in
half-drachm doses in water frequently, or strong tea. Stimulants. Inhalations of ni-
trite of amyl, or one-fiftieth (%) of a grain of nitro-glycerine by mouth, repeated fre-
quently. Recumbent position. Warmth to extremities.
Ether.-Same as chloroform.
Fowler's Solution of arsenic.-Lime-water. Eggs. Milk and lime-
water. Equal parts of lime-water and fixed oils.
Glass.-Use bread-crumbs in large quantities to envelop the particles of glass.
Active emetics, to prevent the glass getting into the bowels. Mucilaginous drinks.
Gold, salts of. Strong solution of sulphate of iron.
Iodine.-Starch. Arrow-root. Paste of wheat-flour and cold water (iodine and
starch form an insoluble compound), then active emetics. Nitrite of amyl. Morphia,
hypodermically, as often as necessary, one-third of a grain.
Iron (chloride, sulphate).-Carbonates of ammonia, soda, and magnesia. Muci-
laginous drinks.
Lead (acetate, carbonate, red oxide).—For soluble salts: white of egg and milk.
DISEASES OF THE ORGANS OF DIGESTION.
633
Glauber's salts, Epsom; Phosphate of soda.
pump. Solid salts: Diluted sulphuric acid.
phine, hypodermically.
Emetic of sulphate of zinc. Stomach-
Castor oil. Poultices to abdomen. Mor-
Lime.-Fixed oils. Stomach-pump. Rinse stomach freely with warm water.
Lye.-Same as alkalies.
Meats (spoiled), Decayed vegetables. -Vomiting. Purgatives. Free use
of powdered charcoal.
Mercury, salts of.-White of egg in cold water or milk, in large amounts.
Stomach-pump, or emetics. Flour-paste made with milk and water. Arrow-root.
Sweet oil and milk. Gruel. Barley-water. In fact, any mucilaginous drink. Stim-
ulants. Morphine, hypodermically.
Morphine.—See Opium.
Mushroom (Poisonous).—Stomach-pump, or emetic. Atropia, one-sixtieth (z)
of a grain, hypodermically, repeated in half an hour, if necessary; or twenty drops
of tincture of belladonna in water. Castor oil, one ounce. Stimulants. Warmth to
extremities, and poultices to the abdomen.
Nux vomica.—Stomach-pump must be used at once, if at all. After spasms
have set in, the use of the tube becomes impossible. Emetics, if necessary, must be
given while patient is under the influence of Chloroform, or hypodermic injection of
one-fifth (1) of a grain of Apomorphia. Animal charcoal in large amounts, or Tannic
acid, or Tincture of iodine, followed by stomach-pump, or another emetic. Bromide of
potassium, half an ounce in water, with or without ten grains of Chloral. Inhalations.
of Amyl nitrite. Relax muscular system by Chloroform or Ether. Curare, one-third
(4) of a grain, hypodermically. Artificial respiration.
Opium.-Stomach pump or emetic. Rouse patient. Flagellation with wet
towel. Pinching. Electric shocks. Ammonia to the nostrils. Walking the patient
is likely to add to his exhaustion, and is not recommended. Coffee. One pint of
strong coffee, injected into the rectum. Pour hot and cold water over his head from a
height, drying him thoroughly after it. Hypodermic injection of Sulphate of atropia
(one-fortieth of a grain), or fifteen minims of Tincture of belladonna by the mouth, to
be repeated every fifteen minutes, if necessary. One-twentieth (2) grain of Atropia is
said to antagonize one grain of Morphia. Nitrite of amyl by inhalation. Artificial
respiration should be kept up at least two hours.
Paris-green.-See Arsenic.
Picrotoxin.-See Nux.
Phosphorus.-White of egg freely. Mucilaginous drinks, with carbonate of
magnesia in suspension. Produce emesis by giving three grains of Sulphate of copper
in water, every five minutes until vomiting occurs. French oil of turpentine, half a
drachm, every fifteen minutes. Avoid oleaginous mixtures; they dissolve phosphorus.
Silver (nitrite of).-Strong solution of common salt in water or milk. Stom-
ach-pump. Later, mucilaginous drinks.
Stramonium.-Emetics. Alcoholic stimulants. Strong coffee. Tannin in
mucilaginous drinks.
Strychnine.-Same as Nux vomica.
Tin, salts of.-Copious draughts of milk. White of egg and water.
Veratrum.-Sulphate of zinc for emesis. Stomach-pump. Full doses of Tinet-
ure of digitalis or of Opium. Stimulants. Strychnine, hypodermically.
Zinc (acetate, sulphate).—White of egg and milk. Solution of Tannin; or decoc-
tion of white oak bark. Solution of Carbonate of potassa or soda. Mucilaginous
drinks. Stomach-pump.
CHRONIC GASTRIC CATARRH.
Synonyms.-Chronic gastritis, Inflammatory dyspepsia, Chronic
inflammatory dyspepsia.
Definition. A disorder of the stomach which depends upon a
chronic inflammation of the gastric mucous membrane, causing im-
pairment of the assimilation of food and of nutrition, with subsequent
634
A SYSTEM OF MEDICINE.
disturbances of the excretory functions; it is accompanied by de-
rangement of the appetite, uneasiness and tenderness at the epigas-
trium, thirst, vomiting of mucus, slight febrile movement, and gen-
eral moral and physical depression.
Ætiology.—Chronic gastritis is likely to result from causes which
may also produce the acute form of gastric catarrh. In fact, often it
is the sequel of an acute attack badly treated; in others, by virtue of
a previously weakened condition of the organ, or by repeated impru-
dence in diet, or by a failure to fully avoid those causes which in the
person concerned create indigestion, there is left behind that low grade
of irritation of the gastric mucous membrane which, once become
chronic, constitutes the disease under consideration.
Chronic gastric catarrh occurs at all ages, with a preference for
mature years, the fortieth to the sixtieth year; it is found more fre-
quently in men than in women, and more often in persons of full
habit. A tendency to this disease is hereditary; at least, observation
shows that members of certain families are quite likely to develop,
sooner or later, symptoms of chronic gastric catarrh; the probability
is that this tendency, as in several other diseases, does not so much
depend upon an inherited taint or upon an inherited peculiarity of
temperament, as upon a natural weakness of the organ itself. A per-
son afflicted with such a predisposition, if prudent and regular in his
habits, may suffer no inconvenience from it, while one less prudent
and less regular in habit may experience a great deal of trouble from
the same source.
Previous diseases of the stomach which have left the organ in an
enfeebled condition constitute an important predisposing cause of
chronic gastritis. Among these diseases, acute indigestion and cer-
tain forms of dyspepsia stand prominent.
Among the exciting causes, errors of diet are of the most frequent
occurrence. Eating too often, allowing the stomach no rest, is quite
sure to bring on chronic gastritis; excessive indulgence in the pleas-
ures of the table, persistent overloading of the stomach, the indulgence.
in articles of diet which are not suited to the digestive powers of the
individual, and improper mastication, deserve mention here. The
latter especially constitutes one of the most common causes of chronic
gastric catarrh, and the national vice of eating so hurriedly that the
food is forced into the stomach before it is duly prepared for reception
there, has resulted in the alarming prevalence of this disorder which,
for the sake of convenience, is generally classed under the broad title
of "indigestion." Some authors maintain that too long-continued
abstinence from food gives rise to chronic gastric catarrh.
The habitual use of alcoholic drinks deserves mention here; the
richer in alcohol such drinks are, the greater their importance as an
exciting cause; hence the especial danger of the free use of brandy.
DISEASES OF THE ORGANS OF DIGESTION.
635
A similar effect is produced by substances which mechanically irritate
the coats of the stomach, and by various drugs which are generally
Mer-
given on account of tonic properties, such as Arsenic and Iron.
cury, Cubebs, and a few others of this class, when taken in too large
doses, or for a great length of time, act similarly.
Chronic gastric catarrh often coexists with chronic diseases of a
wasting character, or with diseases which disturb the portal or ab-
dominal circulation; examinations after death have repeatedly de-
monstrated its existence when during life no symptoms of it had been
observed. It occurs in diseases of the liver, especially in cirrhosis,
and of the heart; also in albuminuria, gout, phthisis, and various
affections based upon the scrofulous diathesis.* Fenwick calls atten-
tion to its occurrence whenever the functions of the excretory organs
are disturbed, or when constipation exists.
The coexistence of chronic gastric catarrh with cancer and ulcera-
tion of the stomach, or with pyloric obstruction, is of frequent occur-
rence, and the connection between them is so readily understood that
it requires no explanation.
Pathology. Usually in chronic gastric catarrh the mucous mem-
brane of the stomach is covered by a thick, viscid, tenaciously adher-
ing mucus. The membrane itself presents abnormal vascularity, is
changed in color and thickness, and at times contains in its substance.
extravasation of blood, the result of rupture of the capillaries.
The color of the gastric mucous membrane varies. It is of a milky
white when fatty degeneration of the glands has taken place, and of a
dark-red, brown, or slate-color when there has existed disturbance
in the portal circulation, as in cirrhosis of the liver or heart affections.
The dark slate-color, most marked near the pylorus, according to
Wilson Fox, is due to the presence of minute black spots which are
thickly scattered over the mucous membrane, and depend on the
presence of pigment derived by imbibition from the hæmatin of the
blood, the result of previous capillary hæmorrhages in the superficial
layers. The increased vascularity of the membrane is usually well
marked, and erosions are often observed.
Thickening and hardening of the tissues are almost always present,
and depend upon an increase of the interstitial tissue between the
glands. The entire membrane is tough, and may be stripped off the
underlying structures in big flakes. At times this thickening is fairly
uniform; but often there is found that mammillated appearance, first
described by Louis, which consists of soft gray, elevated spots, two or
* Dr. Wilson Fox states that chronic gastritis existed in nearly one half of the
number of cases of phthisis examined by him. Dr. H. Jones affirms that in 23
cases of catarrh of the stomach he found tubercles in 4, and disease of the lungs
in 11 more, while in 8 there was disease of the kidneys, and in 3 diseases of the
heart.
636
A SYSTEM OF MEDICINE.
three lines in diameter, separated from each other by well-defined
sulci, bearing a rough resemblance to a "nipple,” as indicated by the
name used to describe them. These excrescences consist of enlarged
glands containing granular epithelium. The sulci, or furrows, which
separate these elevations, are characterized by atrophy of the glands.
and thickening of their walls, the contents of which consist of fat-
granules and a few granular cells.
At times the inner surface of the stomach resembles in appearance
that of the small intestine. This condition is found when the chronic
inflammation has existed for some length of time, and is due to the
projection of villous growths from the tissue which separates the
glands of the mucous membrane. These growths contain, at their
centre, loops of capillary vessels; they may enlarge, unite at their
base, and eventually obstruct the excretory ducts of the glands, thus
producing atrophy of the glands. Atrophy of the glands usually
occurs in scattered groups, having the appearance of white spots
dotting the mucous membrane; in some instances it affects the deeper-
lying tissue, leading to a more general breaking down, which may in-
volve the capillaries and smaller arteries.
Sometimes cysts are formed by a thickening of the membrana
limitans, an irregular narrowing of the tube, and obstruction resulting
therefrom, with subsequent distension below the point of constriction.
The pathological changes in gastric catarrh not unfrequently involve
the submucous and muscular tissues, either in the process of fatty de-
generation or by a simple hypertrophy of the underlying, more par-
ticularly of the muscular, connective tissues. This thickening of the
walls of the stomach may cause constriction of the pylorus, with sim-
ultaneously existing dilatation above the stricture.
With the exception of the increased vascularity of the mucous mem-
brane, of which mention has been made, nearly all the structural
changes and abnormal appearances indicated are most commonly
found in the pyloric portion of the stomach.
Semeiology. Since chronic gastric catarrh occurs so frequently
in connection with other diseases, it is not always an easy task to rec-
ognize its existence, or to describe its symptoms. This difficulty is
increased by the fact that patients who suffer from this pathological
condition at certain periods, and often for some length of time, seem
perfectly free from any indication of gastric disturbance, until some
indiscretion or error in diet precipitates the return of the difficulty;
this latter feature is of some diagnostic value.
The gastric symptoms, of course, point in the direction of indiges-
tion. There is rarely present any degree of pain at the stomach, but
soon after eating, from a few minutes to half an hour or an hour, the
patient experiences a feeling of fulness, oppression, weight, and vague
discomfort at the stomach, with a sensation of constriction about the
DISEASES OF THE ORGANS OF DIGESTION.
637
waist. There is a marked bloating in the epigastric region, the result
of the formation of gases, due to the retarded and impaired digestion,
and to the decomposition of food in the stomach; the latter depends.
upon the changes in the gastric juice which has become alkaline, and
to the inefficiency of the movements of the thickened walls of the
stomach. This feeling of fulness is somewhat relieved by frequent
eructations of gas, often accompanied by mouthfuls of partially di-
gested food and of copious amounts of a fluid which is exceedingly
rancid, sour, and at times painfully irritating to the oesophagus and
throat; in popular parlance this latter symptom is called heartburn.
The presence of well-defined pain at the stomach is rarely observed,
and, when present, deserves most serious consideration, since it points
to other, and grave, diseases of the stomach. There is likely to be
present a constant tenderness, varying in degree, and most noticeable
when the fulness and constriction is at its height; it is found in most
all cases where there exists a congested state of the liver. Not unfre-
quently the patient complains also of a feeling of warmth at the
stomach, with a raw and burning sensation within the organ. The
flatulence may not be confined to the stomach, but may become in-
testinal as well, accompanied, in such a case, with a feeling of in-
creased discomfort, particularly in the right hypochondriac region.
These gastric and intestinal symptoms, more especially the acidity
and burning at the stomach, are occasionally relieved by eating, par-
ticularly, in the writer's experience, of dry, coarse bread; the relief is
usually for a short time only, and may be followed by an aggravation
of all the symptoms. The acidity of the eructations is quite diagnostic
and depends upon acetous fermentation, the natural consequence of
conditions already mentioned, and no doubt frequently set up by the
retention in the gastric mucus of bits of undigested food.
These disturbances are frequently accompanied by a tormenting
nausea, but vomiting of food rarely occurs. Profuse vomiting of
stringy, glairy mucus, however, occurs in cases depending upon, or
complicated with, albuminuria, phthisis, and in the chronic gastric
catarrh of drunkards. In these cases there takes place a profuse secre-
tion of mucus, which is ejected in astonishingly large quantities. At
times this vomiting is nearly constant; again, it occurs every few days.
only, usually after breakfast. Frequently, in such cases, there is
little sickness, and a noticeable absence of gastric symptoms during
the intervals between the attacks. The chronic gastritis of drunkards
is characterized by the almost certain existence of this symptom; in
such cases blood is often mixed freely with the mucus, and hæma-
temesis is a not uncommon occurrence. These cases present also
characteristic nervous disturbances, easily recognized derangements
of the liver, and that painful sense of sinking and horrible feeling of
638
A SYSTEM OF MEDICINE.
goneness at the stomach which can be relieved only by renewed in-
dulgence in heavy stimulants.
The appetite is usually fitful; more frequently it is almost wholly
wanting, or there exists a craving for highly-spiced dishes or for special
dishes to the exclusion of staple foods. Sometimes the patient pre-
fers to abstain from eating for a long time, and then suffers from faint-
ness until he eats, usually voraciously, and with disastrous effects.
Others have a normal desire for food, but a few mouthfuls suffice to
bring on a feeling of repletion, and the patient either leaves the table,
or continues the meal at the expense of his comfort.
Thirst is usually present. Drinks, hot or cold, are not only used
freely at the table, but between meals and in the evening. Cold drinks
are taken by preference, but they often so seriously aggravate the diffi-
culty that the patient is taught to abstain from them, and to satisfy
himself with warm drinks, not daring to partake freely of even these
without experiencing much discomfort.
The tongue is variously coated. In many cases it presents only an
occasional whitish fur on the dorsum. In others it is large, flabby,
and shows the indentations from the teeth. When the liver is con-
gested, the coating of the tongue is thick, yellowish, or of a dirty brown.
In cases which appear in connection with those chronic diseases which
are characterized by an elevation of temperature, and particularly in
their latter stages, the tongue is of a bright red color, pointed at the
tip, with marked prominence of the papillæ, and presents a raw ap-
pearance.
The mouth presents several other important symptoms. The
breath is usually offensive, and the taste, particularly in the morning,
is very disagreeable. The catarrhal state is often found well pro-
nounced in the oral mucous membrane; the lips are dry and
cracked, the fauces are inflamed and even slightly ulcerated; the
pharynx partakes of the irritation, showing granular inflammation,
with the secretion of ropy, tenacious mucus, and frequent hacking
cough.
The gums become spongy, puffed, retracted from the teeth, and bleed
easily; irritation of the salivary glands occurs, giving rise to profuse
salivation, especially noticeable and annoying at night, when the
saliva discharges freely from the mouth upon the pillow; this exten-
sion of the catarrhal state to the salivary glands leaves the tongue dry
and feverish, or covered with a creamy white mucus.
Commonly the bowels are constipated, but if the intestine partakes
of the catarrhal inflammation, a more or less habitual diarrhoea de-
velops. If constipated, there is present considerable flatulence, with
colicky pains and general intestinal uneasiness, pressure in the rec-
tum, dull frontal headache, weariness, general indisposition.
stools, usually of pale color, are passed in dry, small lumps, with con-
The
DISEASES OF THE ORGANS OF DIGESTION.
639
siderable straining, and are often covered with glairy mucus.
Hæmor-
rhoids are a legitimate result of this condition. These spells of consti-
pation are at times relieved by a number of frothy, diarrhoeic stools,
containing food in a fermented state, often very irritating to the anus,
and accompanied with colic and emission of flatus.
Symptoms of jaundice appear when the catarrh extends to the duo-
denum and causes obstruction of the biliary passages. This condi-
tion is of not uncommon occurrence, and deserves careful considera-
tion at the hands of the practitioner.
The urine exhibits abnormal conditions. Its specific gravity depends
largely upon the amount of fluids taken, and is usually higher in the
evening than in the morning, owing to the increase of the urea as the re-
sult of food taken and of exertion made during the day. The deposits
consist of urates, oxalates and earthy phosphates; the secretion con-
taining a large amount of the phosphates is generally alkaline,
cloudy when first voided, and after standing in the vessel becomes
iridescent.
Chronic gastric catarrh generally produces a slight elevation of tem-
perature, mal-nutrition, and subsequent nervous depression and irri-
tability. The pulse is rarely disturbed save at times when the exces-
sive flatulence interferes with the regular action of the heart, or when
there exists a marked feverish exacerbation at stated periods; usually
it is slow, regular, and full. A slight feverish reaction, accompanied
with malaise and, perhaps, shivering, is not at all unusual; and cases
are not unfrequent in which there is observed toward evening a decided
elevation of temperature, with dryness and heat of the extremities,
full and compressible pulse, dull frontal headache, and violent thirst.
Other patients are habitually chilly, suffer severely from dull, heavy
headaches, and are exceedingly sensitive to every change of tempera-
ture.
The effects of mal-nutrition are shown in the dry, sallow, wrinkled
appearance of the skin, and in the predisposition to eruptions on the
skin; this tendency is most noticeable in persons of a scrofulous habit,
and in them the appearance of an eczema or impetigo is likely to be
followed by a prompt amelioration of gastric symptoms. The hair
becomes dry and prematurely gray, and baldness sets in; the nails
and teeth become brittle, and are easily broken. The countenance
appears old and weary, the extremities are habitually cold, and pro-
gressive emaciation of the whole body indicates the profound disturb-
ance in the digestive functions.
The nervous system, in the later stages of chronic gastric catarrh, is
visibly affected. Weariness and indisposition to make an exertion of
any kind are observed; the patient complains of an infinite variety of
aches and pains, usually lancinating, at times rheumatoid in character,
in the trunk or limbs, in fact, almost everywhere; he becomes impa-
640
A SYSTEM OF MEDICINE.
tient, timid, despondent, incapable of exercising his formerly sound
judgment, irritable, fickle, and disagreeable to all about him, at times
so profoundly depressed as to be a confirmed melancholic. Wakefulness.
and sleeplessness at night commonly coexist with this state of mind,
while in other cases sleep is so profound and so heavy that the patient
awakens tired, weary, wholly unrefreshed, and requires some time be-
fore he is able to enter upon the duties of the day.
The headache of chronic gastric catarrh bears no resemblance to the
agonizing sick headache which accompanies the acute form. It is a
dull, heavy, pressive ache in the occipital or frontal region, often con-
sisting more of a feeling of discomfort than of a well-defined ache; it
is occasionally associated with a mild degree of vertigo.
Diagnosis. In a thoroughly chronic case, the diagnosis of chronic
gastritis, though not extremely difficult, requires considerable care, es-
pecially so since practically an important part of the diagnosis consists
in the determination of the primary cause, upon the prompt recognition
of which depends, to a very large extent, the successful treatment of
the case.
A careful study of the symptoms, as above described, usu-
ally suffices for diagnostic purposes. A differential diagnosis, however,
between atonic dyspepsia and chronic gastric catarrh, between neurotic
and catarrhal conditions, and, finally, between ulcers and cancers, and
catarrh, frequently presents some difficulty. Atonic dyspepsia, in
contra-distinction to chronic gastric catarrh, presents a correspondingly
small degree of gastric uneasiness and tenderness at the epigastrium.
The absence of fever, the pale, broad, flabby tongue, the comparative
mildness of the constitutional symptoms, the atonic deficiency of the
appetite, the usual absence of thirst, and the uniformity of the course
of atonic dyspepsia will determine the diagnosis. The gastric disturb-
ances which arise from an abnormal condition of the nervous system,
or in which free vomiting exists as the result of nervous derangements,
are accompanied quite often with a high degree of epigastric pain and
uneasiness without presenting those direct symptoms of digestive dis-
turbance, as pyrexia, thirst, flatulence, acidity, and impairment of nu-
trition, which belong to catarrh. The vomiting, also, in the former
differs from that of catarrh, and in the latter almost always contains
mucus, which is not likely to be found in the former; symptoms be-
longing to the hysterical condition, if present, are easily recognized,
and decide the diagnosis.
A differentiation between ulcer or cancer and catarrh of the stomach
is particularly difficult in the presence of hæmatemesis. It must be
borne in mind that in catarrh the vomiting of blood is nearly always
associated with congestion and indications of obstruction to venous
circulation, with evidence of disease of the liver, heart, and lungs; and
the bleeding is not likely to be excessive or long continued. The sen-
sitiveness to pressure in the epigastric region in ulcer or cancer is
DISEASES OF THE ORGANS OF DIGESTION.
641
much more severe than in catarrhal affections, and in the former is
closely confined to one spot, while in the latter it extends over a larger
surface. The existence of ulcer and cancer is also accompanied by a
rapid loss of strength and flesh, and pallor of the face and lips, which
are not found in catarrh. Finally, the existence of a tumor may be de-
tected by physical examination, and in that case positively settles the
question of diagnosis.
Treatment. The treatment of chronic gastric catarrh differs in no
respect from the treatment outlined in the chapters on acute gastritis
and on atonic dyspepsia; the remedies to be employed and their
indications are, in the main, the same; in the chronic form of
gastritis, however, the antipsorics, so-called, occupy an important
place.
To prescribe successfully, the case must be studied from all sides,
and a remedy must be selected which covers both pathological and
symptomatic indications; to depend upon one group of symptoms to
the exclusion of the other is almost equivalent to failure. The dietetic
hints previously given are to be carefully remembered, with a special
reminder of the fact that the cravings of a morbid appetite in chronic
affections of the stomach can rarely be satisfied with that safety to
the patient which exists in similar conditions accompanying the
acute disorder.
PENETRATING ULCER OF THE STOMACH.
BY J. G. GILCHRIST, M.D.
Ulceration of the stomach and duodenum, either separately or to-
gether, is a somewhat common affection, either idiopothic or sympto-
matic, and is spoken of by different authors as penetrating, chronic, or
corrosive ulceration, or as simple gastric ulcer. The condition has been
quite exhaustively studied, the bibliography being extensive, inas-
much as while a simple ulceration is the same in all tissues, yet the
semeiology is quite confusing from the fact that so many gastric dis-
eases present similar subjective features. It was formerly supposed
that the affection must necessarily have a fatal termination; in fact,
the earlier text-books quite unanimously so taught; later research
and examination, however, goes to show that a large number of cases
recover, perhaps the majority, as numerous examples of cicatrization
are recorded. It might be said, in the order of frequency, that the ter-
mination usually is in recovery, more or less complete, fatal hæmor-
rhage, or perforation of the stomach (or duodenum), with death from
peritonitis.
Symptomatology.-The symptoms of gastric ulcer depend largely
upon the seat of ulceration, the cause, and the rapidity of develop-
VOL. I.—41
642
A SYSTEM OF MEDICINE.
ment. The more constant symptoms may be given as pain, hæmor-
rhage, and gastric irritability. There are many cases in which the
symptoms are violent, the suffering intense, and yet the tissue changes
are insignificant. In other cases there may be an entire absence of
any indications of serious disease, and yet the gravest disintegration
be going on. In still other cases the first indication of ulceration may
be a sudden hæmorrhage, accession of severe pain, or an extensive
peritonitis, showing perforation from an ulcer that had been entirely
unsuspected prior to these severe symptoms. As a general thing, it
may be stated, the symptoms are pronounced in proportion as the
case is acute and the progress rapid; safety is, therefore, frequently
predicated upon the chronicity of the process. Location has a very
important bearing on the violence of the symptoms. Thus an ulcer
at, or near, the pylorus, whether gastric or duodenal, will produce
more violent symptoms than one nearer the cardiac orifice, particu-
larly if on the lesser curvature.
Pain is certainly the most pronounced symptom of ulceration, so
much so that when absent, there is wanting an important element of
diagnosis. The pain is commonly described as being of two general
characters, constant or intermittent. The cases I have seen are easily,
as a rule, classified in this manner. In all cases the pain may be
excited by pressure over the seat of ulceration. Considering these
classes separately, we will find that in cases where the pain is constant,
the sufferings are not always acute. Patients describe it as a dull
aching or gnawing sensation, as though they had been lying down
reading, with a heavy book resting on the epigastrium; there is a dis-
position to straighten up occasionally, or to draw a deep breath; and
yet the gait is usually with the body slightly inclined forward. At
first, pressure will relieve the pain temporarily; later, the epigastrium
is tender to the touch; sometimes there is intolerance of the slightest
touch, even the insignificant contact of the clothing. This pain fre-
quently extends through to the back, at a point corresponding to the
painful spot anteriorly. In the early stages, also, there is some con-
siderable amelioration from eating, particularly from large quantities
of food, but soon after it is followed by a decided aggravation. The
pain, as a rule, gradually increases in intensity from month to month,
and after some time is always aggravated by eating or drinking and
by bodily motion.
Soon after eating the pain is often excessive, subsiding after the
stomach is emptied (either by passage of the ingesta into the intes-
tines, or vomiting), and there may be an entire absence of all uneasi-
ness until the next meal. In some cases, a small amount of food, as
a cup of milk, will arrest pain which is severe when the stomach is
completely empty; under similar circumstances, a considerable quan-
tity of food, particularly when eaten hastily, will bring on intense
DISEASES OF THE ORGANS OF DIGESTION.
643
pain, lasting until the stomach is emptied, or nearly so. Under all
circumstances, however, so far as my experience goes, deep pressure
in the epigastrium will cause pain, not merely during the continuance
of the pressure, but lasting for some moments afterwards.
Remission of pain, it must be noted, may continue for days, weeks
or months, but even then there is some tenderness, uneasiness, or other
evidence of a gastric lesion. These variations in degree or variety of
pain it is important to bear in mind, as, while the occurrence may be
considered proof of ulceration, other circumstances corresponding,
its absence is not by any means proof to the contrary. It is impor-
tant to have some correct idea or theory of the causes of pain, and
of the great variety in its manifestations.
Unquestionably, the occurrence of pain in all ulcerations, whether
gastric or otherwise, is due to the implication of nerve filaments. In
the case of the viscera the pain is reflex to some extent, as the sensory
filaments do not convey the same impressions as when cutaneous
nerves are irritated; increased sensitiveness, hyperæsthesia of visceral
tissues, gives primarily reflex motory phenomena; indeed, as we shall
shortly see, vomiting is a constant, or nearly constant, accompaniment
of irritation of the stomach. Now, the occurrence of pain argues an
irritation greater than is simply sufficient to cause these reflex mus-
cular movements. Hence, one of two or three conditions must exist.
First, there is the question of locality. An ulcer situated in the course
of the lesser curvature, along what might be called the upper border
of the stomach, can only be irritated by an unusual amount of foreign
material in the stomach or violent muscular action in disposing of
such material. In other words, there must be contact of the ulcer with
something or disturbance from muscular action, which practically
amounts to the same thing. Or there may be pain from simple dis-
tension, as occurs from accumulations of gas, a frequent condition in
gastric ulceration. With the ulcer in this region of the stomach, it is
farther removed from such influences than would be the case if it were
on the larger curvature or at the pylorus. In the latter case, any food
introduced into the stomach would cause pain, because it must come
in contact with the ulcer. Hence, in one case a small amount of food
would separate the walls of the stomach so that the ulcer would not
be in contact with the opposite surface, and thus give relief of pain
felt while fasting, and at the same time the motions of the organ would
not be sufficiently violent to cause pain; in another case, any amount
of food, no matter how small, must be brought into contact with the
ulcer, and pain is then inevitable.
Secondly. There is a question of the kind of ulcer, and the rapidity
of development. A chronic ulcer, small and, as is usual, proceeding
so slowly that adjacent parts are protected by infiltration and plastic
organization in advance of the ulceration, must give less pain than
644
A SYSTEM OF MEDICINE.
would be the case under opposite conditions, viz., a rapid develop-
ment and considerable inflammation.
Thirdly. Habits of life must exercise an important influence on the
occurrence of pain. Those of sedentary habits, not addicted to the
pleasures of the table, are not, as a matter of course, exposed to the
same provocation to irritate the stomach as those differently circum-
stanced. Not to mention idiosyncrasy, sensitiveness to pain, and
many other accidental factors, it can be at once perceived that the
varieties of pain do not indicate so much the intensity of the ulcera-
tion as they do locality, provocation from habits and personal sur-
roundings, and the causes both predisposing and exciting.
To sum up the question of pain, therefore, I can state that while it
varies greatly in degree and kind, it differs from purely functional
disturbances, as gastralgia, in that it may always be excited by pres-
sure, even during long remissions, and is felt in a circumscribed ter-
ritory.
Vomiting is a symptom of gastric ulcer scarcely second in import-
ance to pain. It is rarely absent, and yet, like pain, there are in-
stances of extensive ulceration in which neither nausea nor vomiting
occurs. There is a wide difference, in different cases, in the frequency
of vomiting as well as in the character of the dejecta. In some, the
smallest quantity of the least irritating substances excites the vomit-
ing; in others, while there may be frequent and copious emesis, there
is neither nausea nor straining. Occasionally there is extreme nausea,
with painful straining, and the amount vomited will be very small.
As with pain, therefore, so with vomiting; the symptom is a charac-
teristic one, highly so, and yet it may be absent entirely, or vary so
widely in different cases that we are at once challenged to account for
the variation. The location of the ulcer and the normal gastric irri-
tability of the individual must both be taken into the account. Thus,
an ulcer at the pylorus would have the effect to produce vomiting
after the food had been some time in the stomach; one at the cardiac
orifice would induce it early, almost as soon as swallowing, more of a
regurgitation than a vomiting. An ulcer on the lesser curvature might
cause vomiting in proportion as the quantity of food was large or
small, or the muscular action more or less violent. The usual course
of procedure is, first pain, followed by vomiting, after which the pain
is less violent, but continues for some moments until the stomach is
quiet again. Furthermore, there are individuals so exceedingly sensi-
tive in this particular that they normally vomit on very insignificant
provocation. Should such a stomach become the seat of an ulcer,
vomiting is frequent and severe, an exaggeration of a normal pecu-
liarity. There are cases, again, of an opposite character, in which
vomiting rarely occurs.
There is much variety, also, in the character of the vomited matter.
DISEASES OF THE ORGANS OF DIGESTION.
645
In some, it will be the food unchanged; in others, partially digested; in
others, quantities of mucus; in still others, more or less bloody. The
location of the ulcer has much to do with determining these charac-
ters. Thus a pyloric ulcer would give rise to vomiting of partially
digested food; so with one on the lesser curvature. A cardiac ulcer
would occasion vomiting of unchanged food. The admixture with
mucus would indicate an accompanying gastritis, with an acute ulcer-
tion; so also when blood is present. A chronic ulceration might de-
termine more or less serum, or acid fluid, and rarely blood.
Hæmorrhage, to some extent, must always be a symptom or accom-
paniment of ulceration of the stomach. In chronic cases the hæmor-
rhage will be small, sometimes insignificant, but some loss of blood is
characteristic of ulceration. Many circumstances govern the amount
of hæmorrhage. Rapid ulcerations may open large vessels, and blood
will then be poured out in quantities; irritation from the food, or
muscular motions of the stomach, may cause slight bleeding. Ac-
cordingly, while hæmorrhage is an important diagnostic symptom, it
may, and frequently does, require close inspection to detect it. It
may appear as streaks or dots in the vomited matter; at other times
as dark clots, almost black, of varying size. Occasionally it is bright-
red blood, arterial and acid, when a large vessel is opened. Usually
the color is dark, presumably from the action of the gastric juice on
it, not necessarily venous, as the color might indicate.
many cases where no blood appears in the vomited matter, particu-
larly when the ulcer is well within the pylorus, or when vomiting is
unfrequent. The blood will then be found in the stool, in form of dark,
tarry masses, more or less copious. Should a microscope be at hand,
the fact of its being blood is readily determined; exposure to the air,
however, will restore something of a red color. Hæmorrhage to any
amount, however, is not of frequent occurrence; weeks may intervene
between the appearances of blood in quantities. Traces of blood,
nevertheless, will usually be found, if not in the vomited matter, in
the stools.
There are
These are the pathognomonic symptoms of gastric ulcer, prior to
perforation. There are many associated symptoms, not characteristic,
and yet assisting in establishing a diagnosis. The ordinary course of
the disease would be as follows:
The earliest symptoms are various phases of indigestion. In some
cases there is loss of appetite, in others it is greatly increased; in all,
it would seem, there is some notable change. The bowels are fre-
quently constipated, occasionally there is diarrhoea, and still less fre-
quently the functions are unchanged. Soon, no matter what the state
of the digestion may be, the patient is greatly troubled with flatulence,
seemingly unconnected with eating, and, later, more or less pyrosis.
The tongue may be reddened or fissured, dry or moist; frequently it
646
A SYSTEM OF MEDICINE.
is unchanged, unless there is much gastritis, in which case it assumes
the characteristic fiery appearance. Pains in the stomach now come
on, vomiting and hæmorrhage, with gradual increase in the intensity
of the symptoms, and a remarkable degree of physical prostration.
Should cicatrization now occur the symptoms will not entirely sub-
side, the contraction from the scar materially and permanently inter-
fering with the function of the stomach. The general health suffers
in these cases of ulceration far beyond what would be expected; the
wearing character of the pain, the vomiting and hæmorrhage, induc-
ing loss of sleep and impaired digestion, to say nothing of the conse-
quences of loss of blood, produce a pallor, an expression of suffering
and physical exhaustion, that bears an exceedingly close resemblance
to carcinomatous cachexia.
Duodenal ulcers present similar symptoms to those above described,
perhaps a little less pain, but other symptoms equally as marked and
severe. The location of the pain is usually to the right of the me-
dian line, but may be so near the pyloric end of the stomach that
mere location will not assist in differentiating.
Such are the symptoms of ulceration up to the stage of perforation
or cicatrization. We have now to consider later manifestations. When
cicatrization is not secured, the case usually terminates either in per-
foration with peritonitis, or perforation with abscesses in various parts
of the abdomen.
Perforation usually comes on suddenly, after some straining effort, a
severe vomiting, a fall, jar, or some unusual occurrence of an accidental
nature. There is immediate and intense pain, associated, according
to some observers, with a feeling of tearing. The least motion aggra-
vates the pain, and as vomiting is usually persistent, the suffering
rapidly becomes extreme. There are rigors, hiccough, and profound
collapse; the surface temperature falls, the face is haggard and hippo-
cratic, the pulse is small and rapid, often imperceptible, and the urine.
is suppressed; in short, there are the common symptoms of collapse
and shock. There may be hæmatemesis, but not invariably. If the
patient survives the immediate effects of the accident, life may be
prolonged for days.
In cases of rapid ulceration, that is, cases in which no adhesions of
the stomach to near parts has occurred, the immediate result of per-
foration is entrance of the contents of the stomach (or duodenum)
into the peritoneal cavity. There are then the usual signs of perito-
nitis; the abdomen becomes exquisitely sensitive and painful; respi-
ration is thoracic, entirely; the patient lies on the back, with the knees
drawn up, and the muscles are drawn up into knots or hard as a
board. Gas escaping from the stomach into the peritoneum, the abdo-
men becomes enormously distended; the liver being pushed back-
wards and upwards, there is tympanitic resonance all over the abdo-
DISEASES OF THE ORGANS OF DIGESTION.
647
men. Peritonitis caused in this way, the entrance of foreign material
into the sac, is practically irremediable by any method of treatment.
Occasionally, by vis medicatrix naturæ, adhesions occur between oppos-
ing surfaces, and the foreign material becomes encysted, forming, later,
abscess, which may point externally and thus save the patient's life.
So, also, in cases that survive these early stages, fluid will collect, be-
come encysted, together with the foreign material, and abscess form.
Such abscesses contract adhesion to near parts, and may discharge
into the rectum, the vagina, or bladder, as well as externally, or may
open into the peritoneum again, and the process be repeated.
Perforation, however, is not always followed by peritonitis, at least
immediately. In chronic ulceration, adhesions frequently form be-
tween the stomach and pancreas, spleen, liver, intestine, or parietes of
the abdomen. When perforation occurs under these circumstances,
there is, of course, no implication of the peritoneum. As a rule, the
adhesions induce an inflammatory or irritative condition of the parts
involved, and hence, perforation is frequently the opening of a visceral
abscess into the stomach. It is obvious that these visceral complica-
tions must furnish a somewhat extensive catalogue of visceral compli-
cations. Abscess, having once been formed, is likely to be chronic,
closing and opening again and again, inducing secondary abscess else-
where, wearing out the patient ultimately, producing pyæmia or sep-
ticæmia, or establishing peritonitis which is rapidly fatal in the ex-
hausted condition of the patient.
Etiology. As is the case in all ulcerations, cutaneous or visceral,
one of three conditions of waste and repair must be present. There is
increased waste, molecular death, with normal repair; there is nor-
mal waste, with deficient repair, atrophic states; there is an elimina-
tion of spoiled, dead matter, in masses. There is relative excessive
waste under all circumstances, it is true, and sometimes the actual
relation of waste and repair cannot be estimated or established.
Nevertheless, it is essential that some theory should be formed, as
treatment must be largely governed by the actual condition of affairs.
Thus, under the first head, there is an actual morbid action at work,
something destructive; under the second, there is some local or gen-
eral innutrition; under the third, there is some mechanical or chemical
cause for the death of the tissues. Under all circumstances, the ulcer
should be placed in the acute or chronic class, for obvious reasons.
When chronic, it is probably atrophic, and hence belongs to the
second class; when acute, it is either symptomatic or traumatic, and
falls within the first or third class. Even when purely traumatic,
we can only consider the exciting cause, as mechanical lesions, which,
in the absence of dyscrasia, should heal promptly. The maintaining
and predisposing cause must always be a matter of conjecture; it can
rarely be definitely settled; yet, when the ulcer falls under the first or
648
A SYSTEM OF MEDICINE.
second class, being either symptomatic or idiopathic, there is usually
a foundation for a rational theory of causation.
- Under all circumstances, a preliminary to ulceration not directly
traceable to traumatism must be a more or less active inflammation.
Let us review the many exciting causes for this. A check of perspira-
tion, or a suppression of some habitual excretion, such as urinary
suppression, and effects of the local application of extreme heat, or
exposure to cold, each and all have the effect to throw increased work
upon other emunctories. Surgical students are familiar with the
frequency with which duodenal ulceration follows extensive cuticular
burning. The increased activity of other excreting or defecating
organs determines a hyperæmia of those parts, which may readily
pass over into an active inflammation, should there be any predispo-
sition thereto from any reason, or should the irritation become unduly
prolonged. With a suppression of cutaneous transpiration it is com-
mon to find the intestinal glands more or less successfully carrying
on double work. There is a loss of compensation in the animal
economy, partially understood, and from it we learn that the success.
of a compensatory hyper-activity depends entirely upon two factors:
first, a normal functional and structural perfection of the organs
engaged in the extra duty; and, second, not too great intensity or
persistence in the exciting cause. It is not difficult to realize that,
with a predisposition to imperfect excretion in one direction and
a frequent demand consequently made upon other excretories to
preserve the equilibrium, some structural change is more or less cer-
tainly to be anticipated. Statistics go far to sustain this position.
Thus it is found, from various reports, that women suffer from gastric
ulcer in the proportion of nearly three to one as compared to men.
It is also found that among women a very large proportion of those
who suffer in this way have been amenorrhoeic, either habitually or
from a suppression of menses from cold or some accidental cause.
Various tables quoted by Wilson Fox, M.D. (Reynolds's System of
Medicine, vol. iii., p. 84) show that the periods between the ages of ten
and fifty, in women, in other words, the menstrual life, furnish by far
the greatest number of cases. Thus a condensed table (loc. cit., p. 84)
from various authorities gives the following results:

AGE.
30-40
10-20 20-30
40-50
50-60 60-70 70-80
Total.
Males,
Females,
2
9
CO
6
8
5
2
1
33
•
13
21
9
15
6
8
3
75
Total,
15
30
15
23
11
10
4
108
•
DISEASES OF THE ORGANS OF DIGESTION.
649
It appears that of a total of 108 cases, 75, or nearly three-fourths,
occurred in women. Of this number, 58, more than two-thirds, suf-
fered during the menstrual period, or between the ages of 10 and 50.
Furthermore, the larger numbers fall under the ages from 10 to 30,
viz., 34 cases, a period of life when exposure to accidental suppression
of the menses is more common; and again, in the periods between
the ages of 40 and 50, when menstrual irregularities from the approach
to and completion of the climacteric are frequent. Whilst all authors,
therefore, have recognized the fact that women are the chosen sub-
jects for gastric ulceration, few, if any, seem to connect this fact with
what I consider an equally important one, viz., that it is women only
who habitually have an intermittent excretion capable of suppression.
The records go to show that tuberculosis, chlorosis, anæmia, and
other debilitating diseases, have frequently an association with gastric
ulcer, all of which adds to the plausibility of my hypothesis.
The question of aetiology, therefore, may be thus summed up: An
essential preliminary is an acute inflammation; the inflammation
may arise from traumatic lesions, from an exaggerated functional
hyperæmia, due either to a suppression of an habitual excretion or
unusual energy or persistence in the excitant; it may arise from
anæmic, or other, states that give low recuperative power or defi-
cient repair. Specific morbid action, as carcinoma, gives similar
· results, but these last always require some exciting cause, productive
of inflammation, precisely as is the case with idiopathic and traumatic
ulcerations. In short, anything, local or general, constant or tran-
sitory, mechanical or vital, that causes hyperæmia or inflammation of
the stomach or duodenum is the first step in the production of an
ulcer. Anything that devitalizes the tissues is likewise causative of
the initial lesion. The maintenance or development of the ulcer now
depends upon the general health of the individual. When there is a
normal relation between waste and repair, the ulcer speedily closes;
when there is a plus or minus on either side, particularly as to waste,
the ulcer will continue and develop.
Pathological Anatomy.-Gastric and duodenal ulcers, non-
specific, present the same general characters as ulcers elsewhere.
Thus they may be shallow, confined to the mucous membrane; or
they may be deep, extending through the muscular layers, and even
to complete perforation; they may extend superficially, or in depth,
or in both directions. They may also be single or multiple. The
rule seems to be, however, a single ulcer, but many others coming on
successively. There are instances, quite numerous, of two or three
shallow ulcers appearing simultaneously, or in quick succession, and
coalescing. When the ulcers are multiple, they are likely to be shal-
low; when shallow, they tend to run together. Under similar cir-
cumstances perforation is less imminent than if the ulcer were single
650
A SYSTEM OF MEDICINE.
and deep. The ulcers are usually circular or ovoid in form, and vary
in size from a diameter of an inch to that of five or six inches. As to
location, they are oftener found in the stomach, next frequently in the
duodenum, occasionally in other parts of the intestinal tract, and very
unfrequently in the oesophagus. Whether in the stomach or duode-
num, they are nearly always found near the pylorus. They have.
been seen in all parts of the stomach. Fox (loc. cit.), quoting from
Brinton, says: "In 220 cases in which the site was recorded,
86 were on the posterior surface; 56 on the smaller curvature; 32 on
the pylorus; 13 on the anterior and posterior surfaces, which fre-
quently existed together and were often opposite to one another; 10
on the anterior surface only; 5 on the greater curvature; and 4 in
the cardiac pouch."
•
The inspection of a gastric ulcer will show the common signs of
acute inflammation very distinctly. The tissues in the neighborhood
of the ulcer are thickened, not from infiltration, but actual cell pro-
liferation and organization. The ulcer being on a portion of the
stomach in contact with other parts, as the spleen, pancreas, liver,
duodenum, or abdominal parietes, as well as the diaphragm, the
inflammatory action is usually extended thereto, and more or less.
intimate adhesions are formed. This materially modifies the case,
and gives a different aspect to the occurrence of perforation. In the
first place, inflammation of the tissue to which the stomach may have
become adherent will not only alter or modify the function of that
organ or part, but will materially change the semeiology of ulceration.
The symptomatology will become so mixed up with indications of
other visceral lesions, that much embarrassment may be found in
diagnosis. Furthermore, there is a promise of abscess of the organ or
part adherent, which may destroy life, inaugurate septicæmia or
pyæmia, or permanently destroy the organic function and usefulness.
As to the relation to perforation, there are some important considera-
tions. In the first place, if the organ to which adhesions exist is a
freely movable one, or moderately so, sudden movements may tear
the ulcer open. Again, the perforation may be hastened by the mor-
bid action extending to the stomach from the inflamed organ; as a
favorable modification, the inflammation being of a low grade of
intensity, or chronic, escape of the contents of the stomach into the
peritoneal sac will be avoided.
Perforation, as a rule, particularly when the opening is into the
peritoneal cavity, is rarely of great size; in fact, in some cases it is so
minute that it may escape detection by ordinary examination. There
are many cases of multiple perforation, the openings being exceed-
ingly minute; this is particularly the case when the ulcer is broad
and of large size. The ulcer being small, it is usually more or less
funnel-shaped, and the opening is single. So far as fatality is con-
DISEASES OF THE ORGANS OF DIGESTION.
651
cerned, a small opening is equally as ominous as a large one, the
resulting peritonitis being as severe when a small quantity of foreign
material is present as when the amount is larger. Occasionally an
opening will be very large, perhaps coextensive with the ulcer. In
these cases there is probably an inflammation of a very high grade of
intensity, one that terminates in gangrene with sloughing.
The occurrence of perforation bears some relation to the location of
the ulcer. An ulcer situated in a portion of the stomach in which
natural muscular movements are more violent, or where tension
would be considerable under certain conditions, would be more likely
to result in perforation than when the conditions were otherwise.
There are another class of cases, according to many post-mortem
records, in which repair will be active in one portion of an ulcer while
the destruction is going on in another. Thus, some ulcers have been
seen in which there was advanced cicatrization in the superficial por-
tion, with characteristic contraction, and yet perforation had occurred.
These cases seem to represent a complete reversal in the ulcerative
process; early in the case they are funnel-shaped, the mouth of the
funnel being in the stomach; later, contraction on the stomach-side.
and extension of the ulceration deeper has resulted in a narrow open-
ing into the stomach and a broad ulcer on the external surface.
(C
Cicatrization, taking all kinds and degrees of ulceration into the
⚫ account, seems to be the rule. Fox (loc. cit.), quoting from reports of
the examination of dead bodies in the hospital in Prague, says:
In
a total of 10,203 bodies examined," there were "126 open ulcers and
224 cicatrices in the stomach and duodenum, representing a frequency
of 3.4 per cent." These tables are quoted by Fox to show the fre-
quency of the gastric ulcer, but they answer our purpose here as
showing the tendency to cicatrization. In many of the cases quoted
there was no history of ulceration, the individuals having died from
diseases unconnected with stomach lesions. Cicatrization, however,
does not always terminate the sufferings of the patient. In many
cases the result is simply to change a graver into a milder malady.
This is due to the contraction of the cicatrix, in obedience to the law
of repair, from which the pylorus or cardiac orifice may become nar-
rowed, perhaps almost or quite impermeable; the form of the cavity
may also be altered sufficiently to greatly embarrass digestion. The
more acute the ulceration, the greater the danger of embarrassing
cicatrization, for the reason that a cicatrix is contracting in proportion
to the depth of the ulcer; this is due to the implication of the muscu-
lar layers. Superficial ulcerations, in which the mucous membrane
alone is involved, heal by a reproduction of the last tissue, and hence
there is no alteration in form or function.
Hæmorrhage, which may occur in almost any amount, arises from
various sources. It may be slight, and come from the rupture of
652
A SYSTEM OF MEDICINE.
capillaries in the granulations, or their erosion by a rapidly extending
ulcer; from a deeply congested mucous membrane, a sort of transuda-
tion; or from slight lacerations of the floor or margins of the ulcer by
muscular action of the stomach, or jars, or tension. It may be more
profuse from opening of veins or arteries. It may be fatal from simi-
lar causes or from the extension of the ulcer deep into the substance
of the liver or spleen, from adhesions of the stomach to these organs.
As a rule, however, hæmorrhage is from small vessels, veins, and
capillaries, as larger trunks notoriously resist ulcerative action. Some
authorities have pointed out that a large vessel in the base of an ulcer
may on this account be considered a barrier to perforation.
The mucous membrane of the stomach is generally hyperæmic, and
somewhat thickened; this is particularly the case in the immediate
region of the ulcer. The distance to which the thickening and hyper-
æmia extends depends upon the acuteness of the ulcerative action.
Summing up the pathology, as outlined above, one fact becomes
very apparent. The imminence of perforation, the danger of cicatricial
contraction, the amount of bleeding, in other words: the promise of
life, depends upon the character of the ulcer whether acute or chronic.
The acute form is the more dangerous as there is less time for the
organization of plastic barriers to perforation, hyperæmia is greater,
and cicatrization is more certainly a source of future trouble from the
depth of the ulcer.
Prognosis.-There can be little question that far more cases of
gastric ulcer recover than perish; yet the disease is one of extreme
gravity, and cannot fail to excite the solicitude of the medical atten-
dant. Death may ensue from two general causes, viz.: perforation and
exhaustion. As has already been stated, perforation may nearly always
be considered as placing the patient beyond the hope of recovery; if
death does not speedily ensue from acute peritonitis and shock, it will
almost surely do so from secondary affections, such as abscess and con-
sequent hectic, septicemia, or pyæmia. When perforation occurs with-
out passage of the contents of the stomach into the peritoneal cavity,
owing to adhesions, the occurrence is not easily recognized. Under
these circumstances, while immediate death is not always to be anti-
cipated, yet the occurrence is scarcely less surely fatal. The promise
of life is in proportion as the course of the disease is chronic and con-
tinuous. When continuous, if improvement occurs, no matter how
gradual, the chances are in favor of recovery. In cases with remittency
in the symptoms, it is very difficult to determine when morbid action
ceases, and hence no promise can be made. With the subsidence of
acute symptoms and a persistence of those of indigestion, there is a
probability of some incapacitating cicatricial contraction, or adhesion,
the significance depending entirely upon the character of the symp-
toms. For instance, should all symptoms of ulcer pass away, and
DISEASES OF THE ORGANS OF DIGESTION.
653
yet food be vomited or regurgitated soon after being swallowed, there
would be ground for a suspicion of stenosis or atresia of the cardiac
orifice. Should the food be vomited some hours after being swallowed,
and changed, there would be presumption of similar obstruction at the
pyloric extremity or in the duodenum.
Finally, it must be remembered that there is always a possibility
that ulcers which have been healed may break open again, or new
ones form, because the causes for the original ulcer will probably re-
main, rendering the individual liable to new or successive ulceration.
Bearing all these facts in mind, a prognosis must always be guardedly
given, even in cases purely traumatic.
Diagnosis. Notwithstanding the symptoms of ulceration would
seem to be pathognomonic and unique, yet it is often a matter of ex-
treme difficulty to differentiate from other gastric diseases. Particu-
larly is this true of gastritis, gastralgia, carcinoma, the passage of gall-
stones and indigestion, and to determine whether the lesion is duo-
denal or gastric. The diagnosis in general, that is, in the majority of
instances, may be quite satisfactorily established by the limited area
of the painful territory, the tenderness, more or less, on pressure, and
the constancy of the pain as to location. It is distinctly localized, and
even during the remissions so characteristic of the disease, the sensi-
tiveness to pressure continues. The greatest difficulty will be found
in the early stages, when the ulcer is either very small or scarcely
formed. The symptoms then are not at all characteristic, and the
question is largely one of mere conjecture. The obscurity in this
stage is not lessened from the fact that treatment based upon the
symptoms alone very frequently disposes of the whole matter, aborts
it, and leaves the observer in doubt that can never be cleared up.
As to carcinoma, the differential diagnosis is more obscure and dif-
ficult. Further consideration of this subject must be postponed for
the present.
A question of some considerable interest is to determine the location
of the ulcer, whether it is duodenal or gastric, and if the latter, in what
portion of the organ. There is great difficulty in deciding between the
duodenum and pylorus. As a rule, when aggravations occur some
time after eating, when it is supposed that the food is passing out of
the stomach, the ulcer may be located in the duodenum; it must not
be forgotten, however, that the time required for the food to pass.
through the stomach is far from being determined, and that the narrow
boundary between the intestines and pylorus makes it very difficult
to locate a lesion by subjective indications. Symptoms coming on
immediately after eating would indicate ulceration at the cardiac ex-
tremity or on the floor. It is said that ulcers of the posterior wall
give greater pain in the back than when on the anterior wall, and that
ulcers anteriorly are more sensitive to pressure or touch. But these
654
A SYSTEM OF MEDICINE.
symptoms are comparative, and, in the absence of a standard of com-
parison, are not of much value. It is also said that ulcers on the
lesser curvature (superior surface) give the minimum of suffering.
Treatment. The treatment of gastric ulcer depends entirely upon.
the stage of the disease at the time treatment is commenced. Thus in
the prodromal stage, the object in view is to prevent the formation of
an ulcer; the ulcer having formed, it is desired to promote early closure
and cicatrization; this having been secured, stenosis or atresia of either.
orifice may demand attention. Should the process not be arrested,
and perforation occur, the treatment is necessarily expectant, when
the contents of the stomach pass into the peritoneal cavity; if the con-
sequences are various visceral lesions, from adhesions, the object is to
hasten the evacuation of the abscesses as they form, and promote closure.
of the cavities. This latter, as well as treatment for stenosis or atresia,
must be largely referred to works on Surgery.
These varied indications, it at once appears, call for an equally varied
treatment. Thus we have hygienic and palliative measures, remedies.
and surgical procedures of the most formidable character to study. In
all stages, however, prodromal, active disease, or sequelæ, remedies on
homœopathic indications will be demanded.
Hygienic measures are such as would be suggested by a review of the
ætiology and symptomatology. For instance, we learn that muscular
actions of the stomach, distension, whether from gas or food, bodily
motions and contact, greatly increase the sufferings. We should
recognize the fact that whatever increases the sufferings, in the same
proportion aggravates the disease. Hence the first indication is rest,
both of the body and the part. If the attack is acute, the patient
should remain in bed constantly during its continuance; if chronic,
he must lie down during a paroxysm of pain or period of exacerbation.
Food should be taken, as starvation increases the sufferings almost as
much as over-feeding; but in order to keep the stomach as quiet as
possible, it must be given in very small quantities, at frequent in-
tervals, and of the lightest and most digestible character. Milk has
long enjoyed a reputation as being the best article of diet. If it
disagrees, it may be thickened with cracker-crumbs, or arrow-root.
Buttermilk is often well borne when pure milk is objectionable. Give
it once in two hours, day and night, in cupful doses, or even smaller,
if necessary. It is even desirable to waken the patient at night, every
two hours, and give a dose-a proper word, in this instance. In very
many cases, the days may be comparatively free from pain, but parox-
ysms occur towards morning, at one or two o'clock. This is because
the stomach becomes perfectly empty, and the ulcer is in contact with
the opposite surface.
There are cases, however, where the smallest quantity of food is re-
jected or causes great suffering. In such an event we have a satisfac-
DISEASES OF THE ORGANS OF DIGESTION.
655
tory resource in rectal alimentation. It must not be forgotton that
food is not only taken to support life, but to keep the walls of the
stomach far asunder, if possible, to prevent contact between the ulcer
and opposite surface. Such contact not only causes pain, but may
result in adhesions or the formation of a second ulcer. If rectal ali-
mentation is desired, we have a choice of several articles of food. H.
Smith, M.D. (Archives of Med., i., p. 120), says on this subject: "What
is the best material to be employed? Milk, raw eggs, animal broths,
etc., are usually employed. Since the publication of Professor Leube's
paper on Rectal Alimentation, in 1872, the preparation which he re-
commended has come largely into use, and to this Dr. Flint gives the
preference. It consists of the muscle of beef, partly digested by an
artificial process, and brought to a sufficiently fluid condition to be
administered by means of a syringe. Life has been sustained for
periods of two or three weeks, or longer, with this preparation alone,
and there can be no doubt that a considerable proportion of it is ab-
sorbed. Yet it is only imperfectly dissolved and semi-fluid flesh, con-
taining a great deal of innutritious fibre, and, as such, appears to me.
to be greatly inferior to the perfectly fluid and wholly absorbable flesh
which nature has prepared in the form of blood." The doctor has
used defibrinated blood, defibrinated at the moment it is drawn, and
finds that three to four ounces, injected into the rectum, will be en-
tirely absorbed in the space of eight or ten hours. His method of pro-
cedure is given as follows: "In urgent cases, and especially when the
stomach cannot be called upon to perform its office, defibrinated blood
may be injected into the rectum in quantities of from one to three
ounces, every two or three hours. For chronic cases, in which it is
designed merely to aid stomach-nutrition, from three to six ounces
may be given once or twice a day. Given at bed-time, it usually
causes no discomfort during the night, and there is only the customary
evacuation after breakfast the next morning. If thought desirable,
another injection may then be given, the recumbent position being
maintained for a few minutes, after which, as a rule, there is no con-
sciousness of anything unusual in the bowel, and the patient may go
about his daily occupation. Any ordinary syringe may be employed,
care being taken to cleanse it thoroughly each time without delay,
lest the valves become adherent and fail to act. It is not necessary
that the blood shall be warmed in all cases; many patients can bear
it perfectly well without. But if the rectum is at all irritable it is best
to put the quantity of blood required into a small tin vessel and set it.
into warm water until it has acquired about the temperature of the
body. Warming the injection also promotes the rapidity of absorption,
and is therefore important when the supporting effect is required with
as little delay as possible." And here I may remark, in passing, when
the food is given by the stomach, it may be warm or cold as the patient.
656
A SYSTEM OF MEDICINE.
may desire. My friend, Dr. E. P. Gaylard, of Detroit, has made use
of defibrinated blood frequently, and has found it to answer his ex-
pectations fully.
In leaving this part of our subject, it must not be forgotten that the
treatment does not begin and end in rest; rest is only an adjuvant,
important, and indispensable, but the cure must be secured by reme-
dies properly selected and applied.
Remedies. Among the earlier symptoms of ulcer, rather the pro-
dromal symptoms, those of gastritis, gastralgia, or the many forms of
dyspepsia are observed. This goes without saying, almost, inasmuch
as inflammation is an essential causative factor. The remedies for
this stage, therefore, will be sought under the head of indigestion or
dyspepsia. Painful flatulence, however, is, perhaps, the most common
preliminary annoyance, and for this I have generally found a remedy
in either Carbo veg., Carbo anim., Lycopodium, or Sanguinaria. It is pos-
sible that these symptoms may be relieved, and yet the formation of
an ulcer go on unchecked. As soon as the existence of the ulcer is
made out, that fact must govern in selecting a remedy.
Arsenic, Phosph., Graph., Merc., and Atropia, have apparently.
been used with greater frequency than any others.
Arsenicum would be indicated when there is the characteristic burning pain,
vomiting after drinking, intense thirst for small quantities, aggravation from cold, and
amelioration from heat. Rapid emaciation, with dryness of the skin, and some ten-
dency to diarrhoea or other disturbance of the bowels.
Phosphorus is to be preferred when there is vomiting of fluid as soon as drank;
hæmatemesis; contractive pain in the pit of the stomach, extending to the left hypo-
chondrium, afterwards to the heart and left shoulder.
Graphites has a constant gnawing pain in the epigastrium, with slimy mucous
vomiting.
Mercurius when the pains are more severe at night, in bed; sweating easily;
diarrhoea; more or less dysenteric.
Atropia is used chiefly for duodenal ulceration when there is extreme sensitive-
ness of the parts to touch or pressure, much belching of wind, with aggravation about
two o'clock in the morning. Many use the remedy empirically for these ulcers, and
certainly with remarkable success.
These indications are simply hints; it will be necessary to select a
remedy with reference to the totality of the symptoms, which are so
largely those peculiar to gastritis that reference must be made to the
chapter treating of that condition.
When perforation occurs, the treatment is purely expectant. Vera-
trum, Camphor, or Arsenic will be of some service, particularly to meet
the shock. Aconite, Belladonna, or Ignatia may be required for the
peritonitis. Hot applications may do something to relieve the pain,
etc., from peritonitis, but the chief reliance must be placed on appro-
priate remedies. Jahr places especial confidence on Phosphorus, prob-
ably on account of the hæmorrhage.
Hæmorrhage is usually unimportant, or rather the amount of fluid
blood, either from the stomach or bowels, is so small that little atten-
DISEASES OF THE ORGANS OF DIGESTION.
657
tion is given to it. When it is profuse, or to an extent to produce
the usual signs of severe bleeding, it must demand immediate atten-
tion. The first indication is to enforce perfect rest on the part of the
patient. If vomiting is present, it must be controlled by ice held in
the mouth, or by an appropriate remedy. Styptics should be given,
salt and water, vinegar and water, or pieces of ice swallowed. The
bleeding having ceased, the least motion may dislodge coagula formed
in the opening into the vessel, and the hæmorrhage be repeated.
Should the bleeding be arterial, from a vessel of size, the blood bright.
red, and exhaustion profound, I do not believe the patient can recover.
The only hope is in procuring perfect quiet, and giving time for the
thrombus to firmly plug the vessel.
There are many questions of surgical interest in cases of gastric
ulcer; a discussion of them is out of place here. Thus, an incurable
ulcer may be excised, the whole of the pylorus or a portion of the
duodenum having been frequently removed with a good percentage
of recoveries. A perforation may be rendered non-fatal by an imme-
diate gastrostomy and excision of the ulcer, and either making a gas-
tric fistula or suturing the stomach wound, at the same time removing
the foreign material from the peritoneal sac. The stenosis or atresia
of the gastric orifices may be overcome and cured by surgical opera-
tion. All such procedures, however, are too formidable for general
practitioners to undertake, and the reader is referred to works on sur-
gery for instruction on indications and methods of performance.
CANCER OF THE STOMACH.
BY J. G. GILCHRIST, M.D.
Cancer of the stomach is a disease characterized by the occurrence of
carcinoma, either primarily or otherwise, in the stomach, pursuing the
general course, presenting the pathognomonic symptoms and showing
the pathological features characteristic of carcinoma elsewhere.
Ætiology.—In determining the causes directly operative in pro-
ducing cancer in any locality, the student at once recognizes the ne-
cessity for grouping them into two classes, the exciting and the pre-
disposing. The exciting causes, in this instance at least, may be de-
fined as such influences as affect all men alike, occurrences to which
all men are exposed. The predisposing causes, likewise, particularly
with reference to the present subject, are such agencies and accidental
conditions as affect the individual rather than the case. In other
words, one set of causes are general, the other special in their nature.
Conceiving cancer to be primarily a modification of cellular produc-
tion or activity, it is possible for the disease to remain latent in the
body, waiting for a favorable excitant to active development. The
VOL. I.-42
658
A SYSTEM OF MEDICINE.
first impulse is in a local demand for repair; the morbid action having
become active, it then continues as a purely local affection for a certain
time. Accident determines the locality, notwithstanding a preference
exists for certain tissues. I am aware that what follows enters upon
debatable ground, but my study and observation lead me to consider
the statements veracious, unless I am very much misled in the inter-
pretation of admitted facts.
The facts, as I take it, are these: A frequent seat of carcinoma is on
the lines of demarcation between different tissues, as the skin and mu-
cous membrane. Hence, we find the lips, nose, anus, etc., presenting
many cases. Next we find that cell-producing parts are chosen seats;
the glands are well known to be quite obnoxious to cancer-formation.
Again, we find organs or parts that are frequently exposed to irritation.
are often the seat of carcinoma. This list includes the throat, the
stomach, the uterus, and many other parts. As to tissue, therefore,
we find the greater number of cancer-formations, and in the order of
frequency, in the glands, the point of union of skin and mucous mem-
brane, and the organs that are, by virtue of their function, exposed to
irritation frequently. Next we learn that while there is no specific
cancer cell, there is a characteristic cellular structure, this being an im-
maturity in proportion to malignancy, and a multiplicity of cell-for-
mation. These facts, I believe, are generally admitted.
Now, a lesion, structural or functional, small or great, determines
an attempt at repair, more or less successful in proportion as the ma-
terial for repair is furnished in proper quality and quantity, and or-
ganization is adequate. Given organization, with deficient quantity,
while quality is at par, and there will be a proportionately defective.
repair. Given a minus quality and organization, and carcinoma re-
sults. Given a minus of quantity and organization, ulceration is the
product. Given a plus of quantity, and the remaining factors minus,
and some form of tumor, other than cancer, will result, depending
upon the other factors acting upon an over-abundant supply of organ-
izable material.
All this leads to one conclusion: The first step in the formation of
any tumor must be a local irritation or lesion, necessitating active re-
pair or increased vital effort. The heterogeneity of the result in carci-
noma is explained by the location, the union of unlike tissues; the
immaturity of the product, to deficient vital energy generally. This
deficiency may be congenital or acquired. It has been observed that
the majority of cancerous subjects are mentally depressed, dyspeptics
perhaps, but there is often, if not always, a history of some misfortune,
some grief, some sorrow, or other morbid moral state that may justly be
considered an essential factor in the case. With this lowering of energy
of nutrition, repair is imperfectly performed, and the foundation for
cancer is laid. As the disease progresses, the morbid action extends
DISEASES OF THE ORGANS OF DIGESTION.
659
from point to point; sometimes the elements are dispersed and the
germs become centres of secondary morbid action. Thus, as time goes
on, the disease becomes more and more general, until late in the case
the primary tumor loses much of its significance except as an impor-
tant element in diagnosis.
The stomach, from its function in the process of digestion, is liable
to repeated physiological hyperæmia, which may readily become pa-
thological if an unusual irritant is furnished. Some indigestible sub-
stance taken into the stomach furnishes the irritant, the physiological
act now being carried over into a permanent pathological one. The
glands found in the pyloric portion, and the slight alteration in tissue
when the duodenum is reached, furnish the essentials to carcinoma
if the predisposition exists.
What has been written refers more particularly to primary cancer;
there are cases, however, in which the disease is secondary upon its
appearance elsewhere. This question will receive attention later, but
it may be noted in passing that the primary disease is unusually scir-
rhous, sometimes epithelial; when secondary, it is more likely to be
colloid, melanotic, or a mixture of the two, or encephaloid.
Symptomatology.-Like many of the gastric diseases, the earliest.
symptoms of cancer of the stomach are far from being characteristic.
They are those of dyspepsia, more or less constant, gradually becoming
severe, until a stage is reached when the occurrence of more alarming
symptoms suggests something of greater gravity. There is pain in the
gastric region, oftener in the epigastrium, not severe at first, and coming
on at long intervals. Later, there is some pain at all times, variously
described as gnawing, boring, or burning. Some time after eating
the pain becomes excessively severe, cutting or stabbing, gradually
fading into the customary gnawing pain and uneasiness. This sharp
pain is also felt after unusual exertion, as a long walk or violent exer-
cise. Late in the case the pain becomes continuously severe, with
periods of aggravation, and may be pulsating, probably from contact
of the stomach, thickened and altered, as it is, with the aorta. Very
early in the case vomiting is a common symptom, not accompanied
by nausea, as a rule. As the disease develops, the vomiting occurs
after any introduction of food, or even drink, into the stomach. At
first the vomited matter consists of the food or drink swallowed, more
or less altered as to the former; sometimes a little bile may appear
towards the last of the act; when the disease has made some progress,
blood may be mixed with the vomited matter, or a little bloody pus.
The act of vomiting causes great aggravation of the pain, particularly
towards the last. The vomiting, pain, loss of sleep, and imperfect nu-
trition, very soon lead to the legitimate result, and the patient becomes
emaciated, haggard, and exhausted. The face becomes bloodless, and
of the waxy appearance noted in extreme anæmia, but there is a yel-
660
A SYSTEM OF MEDICINE.
lowish, cloudy tinge recognized as peculiar to the cachexia of carci-
noma.
Sometimes from the beginning, always from an early stage, there is
a fulness in the epigastrium, which, as the emaciation progresses and
the disease gathers strength, is seen to be caused by a tumor. At first
the swelling can be only indistinctly outlined, the margins not being
readily found. As emaciation increases, and the tumor increases in
size, its boundaries become defined. It is then of the typical scirrhous
form and feeling, when the disease is primary, quite firmly attached,
hard, and nodulated. As its size increases, in the leisurely manner
characteristic of the disease, its weight becoming correspondingly aug-
mented, the stomach is drawn down by the traction, until it may be
found as low as the umbilicus, perhaps even lower. At times the
tumor will disappear without any mitigation of suffering, which, to-
gether with the suddenness of the change, forbids any hope of a cure
being in progress, even by the most inexperienced observer. This
disappearance is now known to be caused by a twist in the elongated
stomach or by the distended colon covering it. The tumor may ulti-
mately break down and ulcerate, when the cachexia becomes rapidly
worse; or it may atrophy and disappear, which is an exceedingly un-
frequent occurrence. When ulceration does not occur, it is only be-
cause life has not been sufficiently prolonged to afford time for this
natural termination.
While there is a single tumor for a long time, in the majority of
cases other tumors appear sooner or later, being the result of an ex-
tension of the disease to the mesenteric glands. These secondary tu-
mors are not as painful as the primary, but are equally hard and
characteristic. They are occasionally so numerous that the abdomen
feels to the hand like a hard nodulated mass, unyielding, and perhaps.
with integumentary as well as deeper adhesions.
As other general symptoms, when the tumor is fully formed, the
bowels become irregular, constipation alternating with more or less.
troublesome diarrhoea. The skin becomes more or less jaundiced, as
the whole system is brought under the influence of the disease, and
life becomes a burden to the most resolute. There is fever of a low
type, perhaps some suppression of urine, death closing the scene in
from eighteen months to two years after the commencement of the
disease.
There is much variation in the symptoms, both as to intensity
and order of development; some of those mentioned may not appear
at all. In some instances hæmorrhage is considerable, the blood
coming up or passing through the bowels in large quantities, uncon-
nected with the occurrence of vomiting. Vomiting itself is not always
present, though usually a prominent symptom. There are even cases
where there is neither pain, vomiting, nor hæmorrhage, the case pass-
DISEASES OF THE ORGANS OF DIGESTION.
661
ing into extreme cachexia with no tumor discoverable by palpation.
Nevertheless these negative cases are very exceptional, the disease
usually running the course already described. The appearance of
the tumor must be considered the most important symptom. This
does not occur, usually, until the disease has been in existence for
some time; sometimes, as has been remarked, it does not appear at
all. The variations in the symptoms, therefore, are not from any un-
usual character of the disease, but from the portion of the stomach
affected. The pylorus being the common site, the symptoms above.
given are characteristic. When other portions of the stomach are
affected the symptoms are correspondingly modified. Thus, if the
cardiac orifice, there is immediate pain on swallowing food or drink,
with immediate or speedy regurgitation. If the lesser curvature, the
symptoms are more benign, and vomiting may not occur. If the
greater curvature, the symptoms will resemble pyloric or cardiac tu-
mor, as one or the other extremity is approached.
Prognosis. The natural tendency of carcinoma of the stomach
is towards death. There are a very few cases on record of what is
called a "spontaneous cure," in which the tumor has undergone atro-
phy, or has been thrown out by ulceration. Such cases are so rare that
the prognosis is always to be considered bad. The tumor being sec-
ondary, death usually occurs within a year; when primary, life may
be prolonged to two years, or a little more. As far as remedies go, I
am sorry to say that there are very few, if any, authentic accounts of
a cure from their use. Treatment, other than radically operative,
seems to exercise no influence whatever, either to cure or to prolong life,
and rarely to palliate. The disease is practically incurable, so far as
any knowledge of the profession to the contrary is concerned. As to
the imminence or nearness of death, in a given case, the physician is
never safe in dogmatizing. Death may occur from exhaustion or
cachexia, the tumor remaining unchanged, occult, to the end. It may
occur at any moment from hæmorrhage, either from a tearing of the
morbid tissue in the act of vomiting, or from ulceration. The tumor
may break down, forming a large gastric ulcer, when hæmorrhage or
perforation with succeeding peritonitis will carry off the patient. Por-
tions of the tumor becoming soft, indicate approaching disintegra-
tion and ulcer. Should the patient already be much exhausted,
speedy death may then be safely prognosticated. If the bodily powers
are but little impaired, the chief danger will be hæmorrhage and per-
foration, in addition to dispersion of the germinal elements, and sec-
ondary tumors in the mesentery and elsewhere. Surgery, it may be
noted in passing, gives some better promise of cure.
Diagnosis. It must be a natural inference from the foregoing that
the diagnosis of cancer of the stomach is not at all times an easy mat-
ter. A tumor which can be discovered by palpation will at once, in
662
A SYSTEM OF MEDICINE.
the majority of instances, settle the questions at issue. As it some-
times occurs that a case will go from first to last without any signs of
a tumor, the physician is compelled to rely upon his judgment in
searching for a rational cause for the evident serious illness of his pa-
tient. Ulceration of the stomach may be mistaken for carcinoma, but
if other evidences are wanting, there are certain ætiological features
that must go far towards indicating the true lesion. In the first place,
carcinoma rarely appears before middle life, while ulceration is more.
frequent before this period. The pain of ulceration is not particularly
acute at all times, in fact there may be long intervals of comparative
freedom from suffering; in cancer, the pain, when present, is continu-
ous, aggravated, of course, in various ways, but the pain is apparently
unconnected with eating, drinking, or any local irritation. The ten-
derness to touch or pressure in cases of ulceration is unique, as com-
pared to cancer; in the latter disease, there is no particular tender-
ness or pain at the time of handling or pressing on the tumor; the
pain comes afterwards. The whole course of the disease in ulceration
may be spasmodic, marked by periods of amelioration, of uncertain
duration, during which the health may be greatly improved; the
course of the disease is chronic, extending perhaps over many years.
Carcinoma gives a continuous and uninterrupted development from
bad to worse; there is no intermission; the emaciation and cachexia
proceed without interruption.
The diagnosis in all cases where no tumor is discoverable is to be
made on the principle of exclusion. Where there is neither tumor,
pain, hæmorrhage nor vomiting, if ulceration on the upper surface of
the stomach, some atrophic disease of the liver, or alcoholism should
be excluded, such profound vital disturbance as always exists can
only be attributed to cancer. The color of the skin should assist in
these obscure cases. There is not the pallor characteristic of anæmia;
it is a peculiar " earthy," yellowish-gray color that is eminently char-
acteristic of the cachexia of carcinoma. The expression of the face is
also sui generis, unlike that observed in any other malady, so far as I
am aware.
Morbid Anatomy and Pathology.-As already stated, carci-
noma occurs in the stomach in the same forms observed elsewhere, and
observes the same general characters. Whilst all forms have been
seen, yet by far the larger number are of the scirrhous variety, although
many times the type is mixed. This is particularly true of primary
tumors; secondary deposits oftener result in colloid or medullary.
The encephaloid and colloid tumors are usually more extensive, that
is, occupy more space than the scirrhous. Occasionally, however, scir-
rhus will cover a wide surface. The usual seat of the tumor, of any
kind, is at the pylorus; next in frequency, perhaps, along the greater
curvature, and next, the cardiac orifice. A peculiar feature is that,
DISEASES OF THE ORGANS OF DIGESTION.
663
while the disease rarely extends into the duodenum, when situated at
the polyrus, yet the oesophagus is commonly invaded when at the op-
posite opening. When situated in either the pylorus or cardia, the
disease usually extends completely around the orifice. The disease
usually commences in the sub-mucous or sub-serous tissues, involving
the mucous tissue last; at least, this is the rule quite generally ob-
served in scirrhus and encephaloma, and probably true also of the
other forms. The morbid tissue is seen infiltrated, as it were, along
the interfibrillar spaces, in the muscular coats, looking like white lines
of cicatricial tissue. The muscular fibres are thus more or less widely
separated, seem to be thickened at first, but later become atrophied,
and disappear. There is some strong ground for holding with WIL-
SON FOX, M.D. (Reynolds's Syst. of Med., iii., p. 113) [Note 3], that the
disease first appears in the "secreting glands of the stomach." The
disease is so commonly of glandular origin in external forms of can-
cer that it is reasonable to suppose it maintains this peculiarity
throughout. At all events, from the fact that the pylorus is oftener
affected, a portion of the stomach in which these glands are particu-
larly numerous, it would seem that the point may be conceded. In
the earlier stages of the disease there seems to be a somewhat widely
disposed thickening of the tissues, rather than a defined tumor, marked,
however, with nodular protuberances that may be considered centres
of development, or glandular enlargements; Dr. Fox has found a dis-
tinct, glandular structure in these masses (l. c.). The mucous mem-
brane is greatly thickened, and resists the encroachment of the disease
for a long time. In fact, I have seen two cases in post-mortem exami-
nations, in which the disease had terminated fatally, with little change
in the mucous membrane, the direction of growth seeming to be out-
wards, towards the peritoneum. The tumor, having once commenced
to form, grows steadily and slowly, contracting adhesions to contigu-
ous parts, and throwing out prolongations, along fibrillar spaces, as is
the usual order of development elsewhere. The peculiar contracting
property of carcinoma is marked; the stomach becomes gradually
thickened, particularly the portions in the near neighborhood of the
tumor, drawn up, and diminished in capacity. The density and weight
of the tumor has a tendency to draw the stomach downwards, some-
times making its long axis almost vertical. The tumor being at or
near the pylorus, the cardiac portion often becomes thinned and di-
lated, although occasionally the whole organ is thickened and con-
tracted. It must be understood, however, that even when the mucous
membrane is little, if any, implicated, yet it is firmly adherent to the
tumor, as is the case with every tissue brought into intimate relations
with a cancerous growth.
A scirrhous tumor is not seldom marked by soft protuberances which
may be either encephaloid or colloid, particularly when appearing
664
A SYSTEM OF MEDICINE.
early in the history of the tumor. Late in the case, such soft places
indicate points of disintegration, which, if life is sufficiently prolonged,
will break down into ulcers, rapidly extending, and very speedily
causing death. If not before, certainly with the commencement of
softening, a rapid dispersion of the tumor occurs. The lymphatics
will become enlarged, thickened, and ultimately destroyed; glands
will be swollen and take on cancerous characters, until, in some in-
stances, the peritoneum, intestines, and smaller viscera will become
blended in an almost indistinguishable mass. Veins will become oc-
cluded and obliterated; small arteries may be perforated, giving rise
to fatal hæmorrhage, or destroyed like the veins. Large vessels, even
the aorta, may share a like fate, and the thoracic duct partakes in the
general destruction. The extent to which this destruction of organs
and parts may proceed depends entirely upon the endurance of the
patient. Such is the natural history of the disease, and if all these
possible changes are not found, it is because the patient succumbed
before they could be accomplished.
As to melanotic deposit, it rarely occurs in the tuberiform variety; it
is usually punctated, or infiltrated in streaks, oftener in connection
with colloid or encephaloid. There are a few cases in which distinct
masses have been observed, perhaps as large as a cherry.
Notwithstanding the natural termination of cancer is in ulceration,
yet it very seldom occurs that perforations leaving an opening into
the peritoneum are found. The chronicity of the process, together
with the natural tendency of the disease to contract firm adhesions.
between near parts, sufficiently accounts for the rarity of such occur-
rences. Ulceration sometimes has more of the characters of gangrene
and sloughing. Large masses, particularly of colloid and encepha-
loid growths, are thrown off, often producing violent hæmorrhage.
This has led some to suppose that a spontaneous cure is possible,
the tumor being thrown out entire. There are records of such an oc-
currence in external or cutaneous, but few, at least of undoubted au-
thenticity, of visceral tumors.
Treatment.—Medically speaking, cancer of the stomach is an
absolutely incurable disease. There are reports of cases going to
show the contrary, but in every instance where I have traced them to
their origin the reporter is doubtful of his diagnosis, the termination
of the case was unknown, or there was little faith to be placed in the
diagnosis. From a surgical point of view there is a much better
prospect. Many cases have been cured, although the greater number
die. Excision of the tumor has been curative in a goodly number of
cases; the indications are that the growth shall be of short duration,
cachexia not established, and no secondary formations. In cases of
a later stage, where an operation of excision promises nothing, life
has been greatly prolonged, and the patient made comparatively com-
DISEASES OF THE ORGANS OF DIGESTION.
665
fortable by attaching the duodenum to the greater curvature, or else-
where, thus isolating the pylorus. But these questions do not belong
to our present inquiry; the student must go to works on surgery.
Whilst medicine has nothing to offer for the cure of cancer of the
stomach, it may do much to relieve suffering. And yet, even here
the results are so slow and imperfect that I think humanity would
commend those who give even the transient and unsatisfactory relief
derived from opiates. It is admitted that such treatment is unsci-
entific, and not curative; yet there is no treatment, so far as we know,
that is curative, and the narcotic is not given with any idea of curing.
The patient will die, do what you will, and if, as I have heard re-
marked, it is questionable whether it is desirable to prolong a life of
such hopeless suffering, humanity would suggest the propriety of
hastening death. Nevertheless, there are quite a number of perfectly
authentic reports of cases in which pain had been mitigated and life.
unquestionably prolonged by a careful selection of remedies.
Phosphorus, Lycopodium, and Arsenic seem to be the remedies oftenest
indicated. Probably Arsenic will oftener be useful than any other.
Lapis alb. has been used empirically with some success.
HEMATEMESIS.
Synonyms. Hæmorrhage from the stomach, Bleeding from the
stomach.
Definition.-Vomiting of blood, depending upon a variety of
causes.
Etiology. Hæmatemesis must be considered in the light of a
symptom which is liable to occur in connection with, and as a part of,
a variety of morbid conditions, and which at no time is of pathogno-
monic value. It is due to bleeding from injured blood vessels or is
the result of changes in the constituency of the blood itself.
Hæmorrhage from the larger vessels is likely to arise from gastric
ulcers, usually of the chronic variety. Copland, Virchow, Fenwick,
and others have shown that an atheromatous condition of the arteries
of the structures which surround the gastric ulcer frequently exists in
such cases, tending to rupture of the vessels and hæmorrhage. The
splenic artery, the coronary, and the superior pyloric, in the order of
their mention, are likely thus to give rise to hæmorrhage. Not un-
frequently, however, neighboring organs, as the liver, spleen, or pan-
creas, suffer from ulceration, and the bleeding takes place from them.
The ulcer itself, even in cases of fatal hæmorrhage arising from it,
may be exceedingly minute. The frequent occurrence of hæmorrhage
from a gastric ulcer is shown by statistics; thus Dr. H. Bence Jones,
in seventy-two cases analyzed by him, found gastric ulcers in no less
than forty cases. In cancer of the stomach the tendency to active
666
A SYSTEM OF MEDICINE.
hæmorrhage is not so pronounced; bleeding here takes place in small
quantities, and often with much persistency; the blood is acted upon
by the gastric juice, and assumes a "coffee-ground"
coffee-ground" appearance,
which in itself always constitutes strong proof that bleeding in small
quantities has taken place from some surface. Again, an aneurism.
may rupture and empty its contents into the stomach; or hæmorrhage.
may take place into the oesophagus, either from an aneurism or from
the rupture of a blood vessel as the result of malignant disease. In
either case the blood finds its way into the stomach, and is then
ejected by the act of vomiting. Mechanical injuries, as in the case
cited by Fenwick, in which the aorta was perforated by a fish-bone,
may also cause violent and fatal hæmorrhage from the large vessels.
Hæmorrhage from the capillaries may result from blows upon the
stomach, or from similar injuries, but more frequently depends upon.
obstruction in the portal circulation, such as occurs in cirrhosis and
other diseases of the liver. Thrombosis of the portal vein, due to a
clogging of the portal vein or of its large branches with blood-clots or
cancerous matter, is a rare accident, and universally proves fatal.
Certain affections of the heart, particularly a narrowing of the mitral
orifices, and of the lungs, are often responsible for hæmatemesis. Fen-
wick is inclined to the belief that in the former the bleeding takes
place from the hæmorrhagic erosions of chronic catarrhal gastritis
which is so likely to coexist. The bleeding due to violent congestion.
produced by epilepsy and strangulation, conditions resulting in as-
phyxia, deserves mention here. The corrosive poisons, by their chemi-
cal action upon the mucous surface of the stomach, produce capillary
hæmorrhage. The hæmatemesis of new-born children, which so
frequently terminates fatally, is presumed to depend upon obstruction.
of the circulation, either portal, cardiac, or pulmonary, although the
question of an inherited hæmorrhagic tendency might well be raised.
Hæmorrhage from the stomach may occur from changes in the
blood itself which so affect this fluid that under the pressure of the
circulation it transudes through the walls of the blood vessels. The
nature of these changes is not known,-it is an open question whether
they depend upon a deficiency of fibrin in the blood or upon some
change in its constituency which deprives it of the power of coagula-
tion. It is likely that the hæmorrhages of malignant fevers, cholera,
purpura, scurvy, and jaundice are due to this change in the constitu-
ency of the blood, although several authorities maintain that they
depend upon altered conditions in the coats of the capillary vessels.
It has been repeatedly affirmed by excellent authorities that
hæmorrhage from the stomach may occur in place of, and result from,
circulatory disturbances caused by suppressed menstruation; the cor-
rectness of this statement has been persistently denied by other,
equally weighty, authorities. Valleix has analyzed a series of twenty-
DISEASES OF THE ORGANS OF DIGESTION.
667
seven cases of vomiting of blood; five of these cases, after a most
thorough examination of all the circumstances bearing upon them, he
was forced to consider cases of vicarious menstruation; at least no
other hypothesis could account for their occurrence or for the con-
comitant symptoms accompanying them. A similar vomiting of blood
has at times been observed to occur in pregnant women.
Symptoms. A feeling of sudden faintness, accompanied with
heat, fulness, and weight at the stomach, pale face, soft and feeble
pulse, is followed by nausea of short duration, and vomiting of blood;
prostration and, in severe cases, syncope soon result. The symptoms
correspond in intensity with the rapidity of the bleeding and with the
amount of blood lost. When the amount is small, the blood is seen
in patches on the volume of digested food or of the mucus vomited.
When the hæmorrhage proceeds slowly, the gastric juice acts upon it,
preventing its coagulation, and the blood appears in a dark, digested
mass, showing under the microscope flakes or granules of pigment,
the remnants of the red corpuscles. Hæmorrhages from large vessels,
when the blood is thrown up quickly and is not exposed to the action
of the gastric juice, are bright, fluid, and, in some cases, of alkaline
reaction. Frequently a portion of the blood passes into the intestines,
and is discharged in black, tar-like stools.
The attack of bleeding may not recur for years, if ever; in some
cases, especially in chronic ulcer of the stomach, it has been observed
to recur at stated intervals. Fatal cases terminate by syncope.
Diagnosis. It may become necessary to determine whether a
dark chocolate-brown mass consists of blood, bile, or food chemically
altered; to determine this question we depend upon the color of the
vomited matter and upon the evidence of chemical analysis and of
the microscope.
The blood ejected does not necessarily come from the stomach, as
has already been pointed out; it may arise from some portion of the
intestine, mouth, throat, œsophagus, or lungs, and it may be of some
importance to establish, approximately at least, the source of its
origin. This task is one of exceeding difficulty in most instances,
because the blood taken into the stomach from other parts is subjected
to the same influences which operate upon that coming directly from
the stomach, and necessarily partakes of its characteristics. If blood
is discharged from the bowels, we may approximate in some cases the
locality from which it comes by remembering that the amount of
fæcal matter mixed with it grows less and less toward the lower por-
tion of the alimentary canal.
A differentiation between hæmorrhage from the lungs and from the
stomach is most frequently demanded. Physical examination of
both the chest and epigastric region will establish the presence of dis-
eases in either, and, in most instances, the evidence obtained will be
668
A SYSTEM OF MEDICINE.
sufficient to determine the question. The quality of the blood in
hæmorrhage from the lungs is likely to differ from that of the stomach;
the former is frothy, light, aerated, bright, non-coagulated, and alka-
line in reaction; that from the stomach is dark, rusty, grumous, and
acid in reaction. If the flow of hæmoptysis or from parts above the
stomach has been swallowed, and is then vomited, it necessarily par-
takes of the characteristics of the flow of hæmatemesis in proportion.
to the time it has been retained in the stomach. It is well to remem-
ber, however, that bleeding from the lungs is almost always preceded
by vague sensations of distress in the chest, difficulty of breathing,
tickling cough, and a bubbling sensation, and accompanied by the
raising of characteristic sputa. Vomiting from the stomach, on the
other hand, is usually preceded by symptoms of indigestion, pain,
nausea, and other, and easily recognized, disturbances in the stomach
or bowels. The entire absence of tickling cough, and the plainly ex-
pulsive effort of the act of true vomiting, would almost determine the
diagnosis.
Prognosis. In the absence of especially threatening symptoms
the prognosis is usually favorable. Death results most frequently
when the hæmorrhage depends upon organic diseases of the liver, and
from three to five per cent. of cases die which depend upon the exist-
ence of chronic gastric ulcer. The clinical bearing and effect of the
great exhaustion and of the anæmia which follow the profuse loss of
blood, should at no time be overlooked.
Remedial Treatment.-Ipecacuanha.-The hemorrhage comes on suddenly
and is accompanied with constant nausea; the blood is dark and sour, or bright red;
coldness and pallor of the face and surfaces; spells of fainting, with great anxiety. Pulse
scarcely perceptible; oppression of breathing; pressure at the stomach; great thirst.
Belladonna.-Congestion. Fulness and warmth of the stomach; face con-
gested and bloated, or deathly pale; ringing in the ears; flickering before the eyes;
throbbing in the head and stomach; the blood feels hot.
Phosphorus.-Especially adapted to persons of hæmorrhagic diathesis; bright
red blood; drowsy feeling, and heat in the pit of the stomach with distension. Pallor
of the mucous surfaces, lips, tongue, and gums; thirst for cold water; pulse quick,
prompt; empty, gone feeling in the abdomen and stomach; urine dark; skin warm,
partially moist.
Arsenicum.-Quite useful in cases of cancer or ulcer in the stomach, with
hæmorrhage recurring from time to time; constant nausea and retching; roaring in
the head; faintness; cold face and collapsed features; burning at the stomach; great
thirst, wants to drink often and little at a time; quick, thread-like pulse; trembling
anxiety; stitching pain in the spleen.
Aconite.-A much-neglected, but very important, remedy. Vomiting of arterial
blood, with sweetish taste in the mouth and marked distension in the region of the
stomach; præcordial anxiety with coldness of the extremities, and small, hurried pulse;
characteristic restlessness; excruciating pain in the stomach, with gagging and retching;
fear of death, of being moved, of turning. Upon phlethoric young people with dark
hair, Aconite acts with particular promptness. Hempel calls especial attention to the
following symptom of Aconite, which often precedes hæmorrhage at the stomach,
and the reliability of which has been verified by himself and the writer: "Sensation
as of a cold stone lying in the stomach, notwithstanding repeated stools and vomiting."
Secale.—Passive hæmorrhage; blood is fluid, does not coagulate easily, and is of
a very offensive odor; great prostration of the patient; he lies still; no pain. Face,
DISEASES OF THE ORGANS OF DIGESTION.
669
lips, tongue and hands deathly pale; abdomen cold and soft; cold sweat; quick,
thread-like pulse.
Nux.-Hæmorrhage not very copious, but looks and tastes foul; fainting with
weakness; pain in the spleen; vomiting with difficulty; constipation with black
stools.
Carbo veg.-Utter prostration, bordering upon complete collapse. Frequent
fainting; icy coldness of surfaces and of extremities, with hippocratic face; cold breath
small, almost imperceptible, intermitting pulse; wants to be fanned constantly and
hard; blood bright red.
Veratrum alb.-Slow pulse; ashen color of the face; coldness of the surface;
thirst for cold drinks; nausea brought on by moving or rising; cold sweat.
Hamamelis.-Fulness and pain preceding the hæmorrhage; bloody vomiting
and stools; fulness and gurgling in the abdomen; weak and quick pulse with restless-
ness; cold profuse perspiration.
Crocus.-Blood is discharged in long black streaks.
Erigeron.—Hæmorrhage with violent retching and burning at the stomach.
Millefolium.-A domestic remedy which has done good service; severe retch-
ing and vomiting of the blood, yawning and stretching, with drowsiness; violent
cramps in the bowels and stomach. Vicarious menstruation.
Consult also Arnica, Cactus, Ferrum acet., Hyoscyamus, China.
Auxiliary Treatment.-Rest is of the greatest importance. If
the hæmorrhage is at all severe, the head of the patient must be kept
lowered. If faintness exists, ice must be given freely, and brandy is to
be administered per rectum; if given by the mouth, brandy not unfre-
quently aggravates the vomiting. Often ammonia applied to the nos-
tril is grateful, but it must be given with great care. Nutritive enemata
may be administered, if it becomes necessary to support the patient.
The use of styptics is at times advisable. Gallic acid, in ten-grain
doses, frequently repeated, alum in two-grain doses, and the acetate
of lead, are most reliable. The hæmorrhage arrested, the patient must
be kept absolutely quiet, and the greatest pains taken to insure as
near perfect rest to the stomach as can possibly be obtained. Absti-
nence from food, continued for some length of time, is indispensable,
and when food is again given, it should be administered cold in liquid
form, and in small amounts.
STRICTURE OF THE CARDIAC ORIFICE OF THE STOMACH.
Synonyms. Stenosis of the cardiac orifice of the stomach, Ob-
struction of the cardiac orifice of the stomach.
Ætiology.—Reference to stricture of the cardiac orifice has already
been made in the chapter on "Diseases of the Esophagus." It is a
condition of somewhat rare occurrence, and depends in a majority of
cases upon the presence of cicatrices, of ulcers, scirrhous affections of
the œsophagus at, or near, the cardiac orifice, aneurism and other tu-
mors of the œsophagus, and upon the pressure resulting from them,
or from the presence of foreign bodies lodged within the esophagus.
The swallowing of corrosive poisons, by their destructive action upon
670
1
A SYSTEM OF MEDICINE.
the structures, may produce the same result. In exceptional cases,
stricture temporarily exists as the result of spasm.
Pathology. The pathology of stricture naturally varies as the
obstruction arises from different causes. Permanent stricture of the
cardiac orifice in a majority of cases points to the presence of cancer.
The orifice itself is liable to be affected in cases of scirrhus; if the
stricture is situated higher in the œsophagus proper, it usually de-
pends upon the presence of epithelial cancer. The stomach itself pre-
sents no characteristic appearances; it is almost always diminished in
size, at times remarkably so, but is not structurally altered.
Semeiology. The symptoms of stricture of the cardiac orifice may
be summed up in the general statement that the introduction of food
into the stomach becoming an impossibility, starvation must result
unless the stricture can be relieved. The introduction of food into
the stomach is difficult or impossible as the stricture is more or less
complete.
If the obstruction, or stricture, is not complete, fluid may enter the
stomach, while solids are promptly rejected; if complete occlusion
has taken place, the passing of nourishment into the stomach is, of
course, out of the question. The oesophagus then becomes dilated and
forms a pouch in which the food is retained for a varying period of
time, to be eventually returned with certain changes in its appearance
and composition which are worthy of note. If rejected immediately,
the food appears unchanged save by mastication; if retained within
the œsophageal pouch for some length of time, fermentation and pu-
trefaction have taken place in the food, it is mixed and covered with
slime, and during the period of its retention gives rise to horribly
foul eructations.
The act of swallowing is difficult, and not unfrequently partakes of
the spasmodic; partial relief may be given by the passage of a narrow
tube, if the nature of the obstruction permits, through which food can
be administered. Pain in swallowing is not always conspicuously
present unless ulceration exists, when it becomes very severe; it is
usually referred to the ensiform cartilage; a sense of uneasiness and
pressure frequently exists during the intervals between swallowing;
the appetite is unimpaired, and patients suffer intensely from the do-
sire for food; nutrition soon becomes seriously impaired; emaciation
takes place, steadily progressing to absolute starvation, preceded, usu-
ally, by dropsical effusion in the legs and by hectic fever.
The point of obstruction can be located by the introduction of a
bougie, an operation which requires to be performed with patience
and great care, since laceration of the oesophagus is easily produced.
Diagnosis. The recognition of the causes of the constriction de-
pends to a great extent upon careful examination of the character of
the food returned. Cancerous affections are recognized by the exist-
DISEASES OF THE ORGANS OF DIGESTION.
671
ence of characteristic constitutional symptoms and the presence of
blood, pus, or of cancer-cells, demonstrable under the microscope.
Constriction from the presence of cicatrices is not of very frequent
occurrence, unless it be caused by the action of corrosive poisons.
Spasmodic stricture points in the direction of hysteria. The differ-
ence between an organic stricture and that resulting from a simple
spasm is easily shown by the introduction of the bougie, and dilatation
of the oesophagus is determined by percussion.
Prognosis. The prognosis is necessarily unfavorable.
Treatment. The physician's usefulness in the treatment of ob-
struction is largely limited to a painstaking attention to the comfort
of the patient, to the use of such means as promise to lessen his suf-
fering, and to the employment of such means of feeding the patient
as promise to sustain him. The diet is necessarily restricted to nour-
ishing liquids, introduced by a tube as often and in such amounts as
is convenient or possible. Nutritive enemata may be employed, and
frequently are very serviceable.
One of the most annoying features of these cases is the intense
thirst from which the patient suffers, and which to satisfy is practi-
cally a matter of impossibility. The use of baths has been recom-
mended for this purpose, and small pieces of ice, allowed to remain
in the mouth, are frequently a source of much comfort. Dilatation
of the stricture must be employed, and may prove successful if the
presence of cicatricial tissue is responsible for the constriction or oc-
clusion. Gastrotomy has been performed as the last resort. The use
of opiates suggests itself as, at times, indispensable. Constitutional
remedies are of very limited usefulness, and must be selected by the
totality of the symptoms present.
OBSTRUCTION OF THE PYLORIC ORIFICE OF THE STOMACH.
Synonyms.-Stenosis of the pyloric orifice, Constriction of the
pyloric orifice.
Stenosis of the pyloric orifice may be the result of a loss of muscular
contractility, based upon atrophy of the contractile tissue, or upon a
change of the muscular into fibrous tissue. It may also arise from
the presence of cancer, or of cicatrized tissue from an ulcer, or from
ulceration destroying the muscular tissues. In rare cases it depends
upon adhesion between the duodenum, pylorus, and neighboring
parts; external pressure from tumors, as cancerous growths in the
liver, pancreas, small omentum, and of the gall-bladder, may give rise
to this condition.
The symptoms of stricture of the pyloric orifice of the stomach are
the result of obstruction to the passage of food from the stomach into
the intestines,-chiefly vomiting, signs of indigestion, dilatation of the
672
A SYSTEM OF MEDICINE.
stomach with its attending symptoms, to be described hereafter, and
gradual emaciation and loss of strength. Dilatation of the stomach
is always present, and a description of that condition practically com-
prises all there is to be said in connection with this subject.
DILATATION OF THE STOMACH.
Dilatation of the stomach is almost always the result of constriction
of the pylorus. Acute dilatation is an exceedingly rare disease, and
one difficult of recognition. A case is cited, in the fourth volume of
the Pathological Transactions, of a lady who had been under treatment
for piles, and whose abdomen was noticed to have increased in size;
she vomited immense quantities of fluid, which, stopping, was followed
by great enlargement of the abdomen; a post-mortem examination
showed a dilatation of the stomach sufficiently great to hold ten pints
of liquid.
Dilatation of the stomach, independent of obstruction of the pylorus,
probably depends upon malnutrition or enervation of the muscular
coats of the stomach, the result of prostrating disease, affections of the
cerebro-spinal centres, and, perhaps, of hysteria and hypochondria,
in which cases the local disturbances must be the result of profound
nervous prostration. Paralysis of the muscular coat, confined to the
region of the pylorus, and preventing the propulsion of food into the
intestines, may result in dilatation. Hodgkin considers an excessive
and exclusive vegetable diet a probable cause of this affection; Bennett,
of Edinburgh, attributes the occurrence of a case of dilatation of the
stomach to the large quantity of effervescing drinks which the patient.
had taken, and Bamberger makes mention, as a probable ætiological
factor, of dislocation of the stomach and dragging-down of this organ
by omental hernias. In an overwhelming majority of cases, however,
dilatation of the stomach is the result of obstruction at the pylorus,
the causes of which have been enumerated.
Pathology. The chief point of interest is the enormous size of the
gland, which, upon section, contains a large amount of dark-colored
fluid; the stretching of tissues necessitated by the remarkable enlarge-
ment results in the complete absorption of the ruge and in certain
peculiar effects upon the glandular structure. Fenwick states that in
one case he found the tubes visible, but widely separated from each
other, the gastric cells being large and fatty; in another case many of
the tubes had been destroyed, and were replaced by fibrous tissue, the
muscular tissue also being thin and fibrous; in other cases, he states,
the muscular structure is hypertrophied, especially in the pyloric re-
gion. The mucous membrane is usually softened, and even destroyed,
by the action of the acid fluid contained in the organ. Whenever
the muscular coat is hypertrophied, the condition is not as dangerous
DISEASES OF THE ORGANS OF DIGESTION.
673
to the patient as when the structure is thin and almost paralyzed.
The distended stomach naturally becomes dislocated, and its greater
curvature has been known to reach down to the pubes; sometimes the
pylorus may be held in place by adhesions formed, but usually the
organ is dragged down by its own weight.
Symptomatology.-The subjective symptoms of dilatation of the
stomach consist chiefly of disturbances of digestion, and of an un-
natural, and often very prolonged, retention of food in the stomach.
There are vomiting, eructations, and heartburn, not unfrequently acid
from hyper-secretion alone; disturbances of the appetite; emaciation;
constipation, with hard lumpy stools, and, later, dropsical effusions in
the legs. The vomiting is not preceded by nausea, nor is it accom-
panied with much pain or straining; there is present only a feeling of
great fulness at the stomach, and the organ is easily emptied, without,
however, ridding itself completely of its contents. The vomited matter
is chiefly composed of a frothy and acid substance, so sour that it sets
the teeth on edge; it contains the vegetable parasites which exist
during the process of gastric fermentation; there is also found more
or less digested food, and at times, but rarely, an admixture of bile.
The extent of the fermentative change which is produced depends
upon the length of time during which the food has been in the stom-
ach. The matter vomited is frequently very offensive, and the amounts
are often enormous. Vomiting takes place, usually, at intervals of
several days, the length of the interval depending upon the degree of
obstruction, the measure of dilatation, and upon the extent of the
existing paralysis of the muscular coats of the stomach.
If the paralysis of the muscular coat is marked, or if the stomach
is very largely dilated, several days may elapse before vomiting takes.
place; the longer the interval, the larger the amount of matter vom-
ited; but at no time is the stomach entirely relieved of its contents. Bam-
berger states that vomiting may cease if complete paralysis of the
muscular coat should take place.
The appetite is variable; in cancerous conditions it is not only in-
different but bad; in many other cases it is naturally active, and it
even may be excessive. Thirst is frequently present; the tongue
shows no characteristic coating; the bowels are constipated, and the
urine is acid, often depositing lithates.
It is usually not difficult to detect the presence of the stomach in
the different regions of the abdomen by the well-defined outlines of
the smaller curvature, which may be felt stretched across the floating
ribs. There is generally present a hollowness in the epigastric region,
with a marked fulness on the left, and a shallowness on the right, side
of the abdomen. Vermicular movements of the stomach are frequently
seen, and contraction of the organ is readily excited by touch or other
external stimulation. Upon percussion, a tympanitic sound is heard,
VOL. I.-43
674
A SYSTEM OF MEDICINE.
which is dull in the inferior portion of the stomach, which contains
the food. Auscultation gives a splashing sound whenever the patient
moves. The tumor, at times, rises upward, crowds upon the dia-
phragm, and even displaces the apex of the heart upward and for-
ward.
Diagnosis. The diagnosis of dilatation of the stomach depends.
upon the recognition of the symptoms described, and usually is not.
accompanied with great difficulty. The vomiting and the character-
istics of the matter ejected are important signs. In hysteria we find
vomiting, in some respects not unlike the vomiting here described; in
cancer vomiting may also exist, without being accompanied with much,
or any, pain. Uusually, however, in dilatation of the stomach the
condition is so marked that fermentation of the food takes place, thus
establishing an easy differential diagnosis. The presence of the tumor,
the induration of the pylorus, which is nearly always present, and the
vermicular motion over the dilated organ, are of great diagnostic
value. Mere meteoristic distension of the abdomen often exists to a
degree which is likely to mislead; if so, auscultation and the passage
of the sound into the stomach must be called into requisition.
Prognosis. The duration of this disease is chronic, and the termi-
nation usually fatal. If mere thickening of tissue or cicatrization of
ulcers is the cause of the pyloric constriction, the disease runs a slower
course than in the presence of malignant growths. The nature of the
existing obstruction practically determines the final termination. In
quite exceptional cases a process of sloughing may result, and a favor-
able termination may then be had.
Treatment. It is self-evident that careful attention to proper
feeding is of the last importance; food must not only be given at short
intervals and in small amounts, but should consist of such articles of
diet as are chiefly digested in the stomach; among these, meat and
beef-tea deserve mention; food, also, already artificially digested,
should be freely used; vegetables, starch, and fatty substances must
be excluded; milk may be used in very moderate amounts. Rectal
alimentation may become a necessity.
Measures calculated to restore tone to the muscular coats of the
stomach come into play when the dilatation does not depend upon
constriction of the pylorus. The physiological school employ light
doses of strychnine to produce this effect. Recently, Dr. Kuessmaul
suggested the complete evacuation of the stomach by artificial means,
and a thorough cleansing of the organ by the free use of Vichy water,
followed by the administration of remedies intended to neutralize the
acidity of the mucus. It is asserted that under this treatment, of
which complete evacuation of the stomach is the most important feature,
the organ gradually regains its tonicity, the intervals between the
vomitings grow longer, and the patient may eventually recover.
DISEASES OF THE ORGANS OF DIGESTION.
675
The homoeopathic therapeutics are based upon symptomatic indi-
cations.
HYPERTROPHY OF THE WALLS OF THE STOMACH.
Synonyms. Fibroid induration, Cirrhosis, Sclerosis, Plastic
linitis.
Definition. A condition of the stomach which consists of a gen-
eral thickening of all its coats, especially of the muscular and sub-
mucous layer, with a corresponding contraction of the cavity of the
stomach.
Etiology. The causes of hypertrophy are not understood. Sta-
tistics appear to prove that the condition occurs more frequently among
men than among women, and, according to Brinton, at an earlier
period than cancer, the average age in hypertrophy being thirty-four,
while in cancer it is fifty.
Pathology. Hypertrophy of the stomach seems to be the result.
of the abnormal development of fibrous tissue with induration and
simultaneous wasting of muscular structure, the coats of the stomach
varying in thickness from half an inch to an inch, and more. The
result of microscopic examination is largely negative, and gives no
evidence of the existence of cancer-cells; the condition of the coat to
the "feel" and to the knife is tough and cartilaginous; a post-mortem
examination usually reveals signs of general peritonitis, with deposits
of lymph and frequent adhesions; the stomach appears like a round
or oval tumor, firm to the touch, and of smoothness of surface; its
coats are of a dirty gray; the walls are thickened at the expense of
the cavity of the stomach, which is correspondingly reduced in size;
the walls, upon division with the knife, do not collapse. The changes
affect more especially the submucous tissue, but involve all the struc-
tures, the connective tissue included.
Symptoms. It is difficult to recognize this condition in the earlier
stages of its development; hence, our knowledge of its symptoma-
tology is exceedingly meagre. Its approach is insidious, unless the
disease occur as the result of a mechanical injury. There is present,
at first, pain, more or less severe, but at no time sufficiently marked to
greatly annoy the patient. Symptoms of indigestion show themselves,
though not in a well-pronounced form, and the taking of food pro-
duces more or less discomfort and aggravation of the pain. With
these symptoms the patient experiences shooting, darting, wandering
pains in the back and shoulders. The tumor, as the hypertrophy be-
comes more pronounced, is more and more easily distinguished, and
some tenderness to touch appears, which is quite marked when peri-
tonitis exists. The tumor can be felt at any time in the epigastric or
hypochondriac region, is slightly movable, and is resonant on percus-
676
A SYSTEM OF MEDICINE.
sion. Occasionally the hypertrophy is limited to the pylorus, with a
sense of obstruction in that locality. With the progress of the disease
the gastric disturbances become more pronounced and painful. The
appetite is bad, and complete anorexia, with subsequent emaciation,
great physical weakness, and feebleness of the pulse, make their ap-
pearance. The bowels are constipated; vomiting, sometimes of food,
or, again, of mucus, and, later, of blood, takes place, and the patient
finally dies from dropsy or peritonitis. Many of the gastric symptoms
which occur are due to the lessened capacity of the stomach.
Diagnosis. Hypertrophy of the stomach may be confounded with
cancer or with foreign bodies in the stomach. The differential diag-
nosis between hypertrophy and cancer is often very difficult. The
smoothness of surface in the former; the absence of liver complica-
tions and of cancerous affections of other organs; the family history;
the presence or absence of a marked cachexia, must be carefully con-
sidered. "The diagnosis between these two alterations is not always an
easy one, since, as in other parts affected by scirrhus, large tracts of
tissue may often be found presenting nothing but a dense fibrous
structure and a void of the cell-structures which are usually found in
the more open meshes of the stroma, though this, as pointed out by
Rokitansky, can usually be found at the margin of the growth. In
addition to the cancerous character of the margin, the scirrhous growth
is also distinguished by its affecting all coats equally, by the fusion
into a uniform mass of pearly whiteness, and presenting the grisly
cartilaginous texture characteristic of this form, by an immovability
except at the earliest stages, and the mucous membrane upon the tis-
sues beneath, and by the destruction of the normal appearance of the
muscular layer." (Wilson Fox.)
The presence of foreign bodies in the stomach is of comparatively
rare occurrence, and is usually limited to idiots or aggravated cases of
hysteria. Fenwick, to establish a differential diagnosis, recommends
distending the stomach in all doubtful cases by making the patient.
drink freely of soda-water, by which means, in case of hypertrophy, a
decidedly tympanitic sound will be obtained on percussion.
Prognosis.—The prognosis in nearly all cases is unfavorable; but
the disease usually runs a course of several years before a fatal termi-
nation takes place.
Treatment.—Curative measures are almost out of the question.
In homœopathic practice, remedies must be selected wholly upon
symptomatic indications, and an almost endless list of possibly useful
remedies might be furnished. Close attention must be paid to the
diet of the patient, which, in all well-pronounced cases, is to be limited
to broths or other nourishing liquids. Owing to the small calibre of
the stomach, these can be given only in small amounts, and hence
must be frequently repeated. When the pain, particularly in the
DISEASES OF THE ORGANS OF DIGESTION.
677
latter stages of this disease, becomes very violent, opiates may have to
be given in order to afford temporary relief. The writer, in the treat-
ment of a severe case of hypertrophy of the stomach in which the
patient, during the months preceding his death, suffered intensely,
succeeded in getting excellent effects from the frequent administration
of water, given as hot as the patient could bear. It relieved both the
pain and the vomiting, which, in this case, had become a tormenting
symptom.
SOFTENING OF THE WALLS OF THE STOMACH.
Synonyms.-Gastromalacia, Post-mortem softening, Self-digestion
of the stomach.
Definition. Softening of the walls of the stomach, presumed to be
due to chemical action upon the structures.
Dr. John Hunter first observed and described the condition of the
stomach which is commonly termed gastromalacia; since his time it
has been the subject of careful investigation and of earnest discussion,
but no positive results have been reached.
Softening of the walls of the stomach is a condition often noticed in
post-mortem examinations. The membrane of the stomach is exceed-
ingly soft, pulpy, semi-transparent, gelatinous in appearance, and fre-
quently somewhat thinner than natural. In some cases the process
is superficial, affecting only the surface of the rugæ, the underlying
tissues remaining normal. In other cases the entire membrane is in-
volved, and instances occur in which the membrane has the appear-
ance of a thin film of slimy mucus; the underlying structures are
pulpy, tear upon the slighest pressure, and are frequently found per-
forated. Sometimes the entire organ is affected; at others, the process.
is limited to circumscribed portions, with a preference for the fundus
or posterior portions. The limit of the portion affected may be well
defined, or it may blend into the surrounding tissues. The coats of the
stomach, in such cases, present a bluish-white appearance; if the
changes are extensive, they possess a brownish or blackish color, due
to the action of the gastric juice upon the extravasated blood. When
perforation takes place, an effusion occurs into the peritoneal cavity
or into the chest; the edges of this perforation are ragged, thin and,
according to Hunter, "very much resemble that kind of solution which
fleshy parts undergo when self-digested in the living stomach, or when
acted upon by caustic alkali.”
Dr. Hunter, in first describing this appearance, expressed his con-
viction that the changes noted are the result of self-digestion of the
stomach after death, due to the action of the gastric juice on the coats
of the stomach, which, he claimed, had been prevented during life by
the influence of the vital principle. This statement attracted general
678
A SYSTEM OF MEDICINE.
attention and led to careful and many-sided investigations, followed
by a pretty general acceptance of the views advanced. Several authori-
ties still hold that pathological conditions exist in which the changes.
noted by Hunter occur during life; the majority of medical men, how-
ever, presume that the changes, comprised under the term "softening
of the walls of the stomach," are nearly always post-mortem changes.
The following facts speak strongly in favor of the latter view:
a. The changes described have been found in persons apparently in
perfect health, in whom not one symptom existed during life to indi-
cate a lesion of the stomach. b. The forms of softening of the stomach
described as ante-mortem-such as occur in diseases of very small
children, affecting the brain and the gastro-intestinal tract-have been
found after death, while during life the symptoms which are considered
characteristic of softening of the stomach prior to death had not been
observed at all. c. It is known that the gastric follicles, for a consider-
able period after death, give rise to a substance having the properties
of gastric juice, and acting like it upon the entire mucous membrane,
its reaction being decidedly acid; this fact would explain why soften-
ing may occur when the stomach is empty. d. Elsasser has demon-
strated that milk and the amylaceous bodies after death continue to
ferment, and may produce softening of both the stomach and intes-
tines. e. The absence, in the living, of symptoms which would occur
if there were going on during life the profound structural changes.
which terminate in ante-mortem softening of the walls. Among these
symptoms vomiting of blood would almost unavoidably hold a promi-
nent place.
In connection with these propositions, and explanatory of the fact
that in many cases seemingly favorable to the development of ante-
mortem softening, the stomach appears normal after death, or, at least,
gives no evidence of softening, we must bear in mind that the acidity
of the gastric juice is, undoubtedly, often neutralized by the alkaline
reaction of blood in the abdomen. The difference in the structure of
the stomach in different individuals must also be borne in mind. If
soft and tender, it is of necessity acted upon with far greater effect than
when tough and cartilaginous. The stomach of a healthy young child,
for instance, under favorable circumstances, could not long resist the
action of the agents pointed out, while large amounts of gastric juice
could make but little impression upon tissues hardened by the exist
ence of a scirrhous or cancerous affection.
Whenever softening of the stomach occurs before death, a morbid
condition of the organ usually exists which results either in a very free
secretion of gastric juice, or which gives rise to fermentative changes
in the food; milk and amylaceous foods readily undergo such changes.
Fenwick, in speaking on this point, mentions the fact that in animals
who died from the cattle plague, he found the mucous membrane of the
DISEASES OF THE ORGANS OF DIGESTION.
679
stomach very soft. His admission, however, that there was present evi-
dence of gastritis greatly lessens the force of his observation. Again
he states that in certain disorders, as in cancer of the uterus, the
mucous membrane of the stomach is usually found very soft without
presenting the appearance of cadaveric changes, a condition which he
attributes to imperfect nutrition.
Softening of the stomach is of interest only as a purely pathological
question, and has no clinical bearing.
BRIEF REMARKS ON DISEASES AND ABNORMAL CONDITIONS OF
THE STOMACH WHICH ARE OF UNFREQUENT OCCURRENCE.
Contraction of the Stomach.-This condition may be general
or confined to some one portion of the gland. In the former, it is
always the result of prolonged abstinence from food, and occurs in
cases of slow starvation, usually depending upon such diseases of the
œsophagus or of the cardiac orifice of the stomach as prevent the in-
troduction of food into the stomach; in exceptional cases, very long-
continued or excessive vomiting produces the same result. No struct-
ural changes occur, and the stomach can usually be distended by
artificial means. Contractions which are limited to some one part of
the stomach depend upon the drawing together of the orifices of the
stomach, or upon contraction of structures as the result of cicatrization;
in cancer or ulcer of the stomach this condition is of frequent occur-
rence. If the contraction occurs at the pyloric orifice, it results in
hypertrophy of the muscular structure and subsequent dilatation of
the stomach.
Atrophy of the Stomach, if limited to a portion of the gland, is
not of uncommon occurrence, and does not necessarily interfere with
the proper discharge of the physiological functions of the organ.
According to Fenwick, this atrophy of the gastric mucous membrane
may be combined with inflammatory conditions of some of the other
coats of the stomach, and then proves fatal by "exhaustion of the
patient;" or it occurs in cases which are usually classed as idiopathic
anæmia, and is the result of degeneration, as shown by examination
after death. The same author maintains that this condition is not of
unfrequent occurrence in certain cases of cancer of the breast. He
has examined the stomachs of a large number of such cases after
death, finding in them a marked attenuation and diminution of weight
of the mucous membrane and a remarkable deficiency of the amount
of pepsin secreted. He explains upon this basis the fact that often
persons die after an operation for cancer of the breast when there is
but a trifling reappearance of the growth and no great amount of dis-
charge or of bleeding. In the same manner he accounts also for the
gradual loss of strength and of flesh so noticeable in these cases. The
+
680
A SYSTEM OF MEDICINE.
same authority (Quain's Dictionary of Medicine) thus describes the
anatomical characters of atrophy: "In atrophy of the stomach the
mucous membrane usually escapes post-mortem digestion; it is thin,
smooth, and firmly adherent to the subjacent coats. Microscopically,
in the earlier stage of the disease, the solitary glands are enlarged and
filled with cells and nuclei. The gastric tubes, and sometimes the
subjacent muscular fibres, are displaced by these bodies, which are
scattered everywhere through the membrane. The tubes adhere
firmly to each other, but they still contain normal cells. Later in the
disease the solitary glands appear empty in their centres, but sur-
rounded by thick layers of nuclei; the tubes can no longer be traced
throughout their whole extent, but can only be recognized as bulbs
filled with fatty cells, or as lines of cells, whilst the whole tissue is
obscured by fatty and granular matters. In the last stage the solitary
glands have disappeared, and the tubes are replaced by fibres. In
some cases observed by the writer, although the mucous membrane
was very thin, it was so fatty that thirty-three per cent. was removed
when digested in Ether. These anatomical changes seem to produce.
a concomitant decrease in functional power. Post-mortem digestion
seldom occurs, even in the summer, and in one case in which the
writer performed artificial digestion with the whole mucous mem-
brane, only six-tenths of a grain of albumen was dissolved, and in
two others the albumen was only softened. When a similar experi-
ment was performed with the stomachs of persons who had died of
other diseases, four grains of albumen was the average amount dis-
solved, the remainder being softened and translucent."
The diagnosis of this affection can be made only by exclusion of
all other diseases that tend to produce anæmia.
Concretions and Foreign Bodies in the Stomach.-Concre-
tions are composed of indigestible substances swallowed, and are
found in the stomachs of idiots or lunatics, where they may be retained
for a variable period; they produce a more or less violent degree of
inflammation of the mucous membrane, possibly followed by peri-
tonitis or perforation of the stomach. Paper, hair, cotton, and similar
substances are frequently taken by such persons in surprisingly large
amounts. A case is cited by Pollock, first reported by Holmes, of a
young woman, aged eighteen years, who had suffered from a tumor in
the epigastric region, and who frequently vomited after meals. After
her death, “the stomach was opened and was found to contain a large,
compact mass of hair and string, filling the organ in great part; a
small portion was engaged in the pylorus. The hairs were long and
black, and united to one another by the string and dry alimentary
particles; the mass measured six inches in length, three-fourths of an
inch in thickness, and two and a half inches in breadth. Another
mass occupied the upper part of the duodenum and the commence-
DISEASES OF THE ORGANS OF DIGESTION.
681
ment of the jejunum. This portion of the intestine was considerably
dilated; this mass contained fewer hairs and more oakum; it was
fourteen inches long."
Bucknill relates a case of an insane epileptic, who died of perito-
nitis at the age of twenty-two years. "The stomach contained a per-
foration larger than a shilling, colored black, and with ulcerated
borders, which were situated in the lesser curvature of the stomach.
Upon opening the stomach, it was found to contain a mass weighing
fourteen pounds, and composed entirely of cocoa fibres and pieces of
twine. The mucous membrane was healthy except at the ulcerated
spot."
((
The list of foreign substances occasionally swallowed embraces a
large variety. Knives or forks, broken glass, and similar strange
bodies are introduced into the stomach by persons mentally irrespon-
sible, or as a result of accident. Heymann reports a case in which
a child slept with its mouth open, and a mouse suddenly entered it;
the mouse was swallowed, and eventually expelled from the bowels."
Pieces of coin, nails, needles, and other sharp substances are not
unfrequently swallowed, and in some cases remain there for a remark-
ably long period of time, eventually producing fatal results unless
they are expelled through the bowels. The nature of the articles
introduced is frequently astounding. John Marshall reports a case
in which "the stomach of a woman in middle life contained in its
lower part nine ounces of needles of a reddish-black color, but not
rusted, all of them bent or broken, and very sharp. The duodenum
contained a mass of needles united into a sort of very solid bundle;
they were of different sizes, like those in the stomach, and entirely
obliterated the intestinal canal. They weighed a pound in all."
Sonnié-Moret relates the case of a woman in whose stomach were
found "eleven packages of nails, bound together, and some pieces of
brass from a pair of suspenders (160 grammes). These objects had a
black color; the brass had been partially dissolved, and the ends of
the brass were thin and very sharp; the iron was more deeply attacked;
its surfaces presented ridges and notches, and some of the nails had
become converted, so to speak, into threads. The inner surface of the
stomach was pale red, with a few scattered spots of a deeper red; the
greater cul-de-sac had a brownish tinge, and there were some spots of
the same color near the pylorus. The external surface presented,
upon the hypertrophied pyloric portion, some rust spots, the largest
of which was found along the lesser curvature, about two inches from
the pylorus, and was half an inch long and three inches wide. On
this spot the muscular coat was softened as far as the mucous mem-
brane, but the latter presented no change."
Poland saw an autopsy upon a young idiot whose stomach con-
tained two pounds and eight ounces weight of foreign bodies, and who
682
A SYSTEM OF MEDICINE.
died from a perforation of the anterior wall of the duodenum. The
stomach and intestines contained a mass of spoon handles (31) five
inches long, four half-handles, nine nails, half an iron heel, a screw,
and four pebbles.
Perforation of the Stomach occurs as the result of simple or
cancerous ulceration; the contents of the stomach escape into the
peritoneal cavity suddenly and in large amounts, or slowly, from a
perforation usually minute, setting up a peritonitis which in the for-
mer case is violent and rapidly tends to a fatal termination, while in the
latter it is of a lower grade of intensity, and not unfrequently results
in circumscribed' inflammation, with subsequent formation of an
abscess. The accident would occur oftener in the course of cancerous
ulceration did not adhesive inflammation of the peritoneal covering of
the stomach tend to the establishment of adhesion of the stomach,
pancreas, and liver, and thus act as a safeguard against the occurrence
of this accident. Dr. Graves cites a case of perforation caused by an
abscess of the liver, which communicated simultaneously with the
pericardium. Not unfrequently perforation is due to the presence of
foreign bodies in the interior, such as knives, forks, wires, needles, etc.,
and, rarely, to some accident resulting in perforation from without.
The symptoms of perforation are exceedingly violent, and generally
resemble closely those of sudden and violent peritonitis. A sudden
and severe pain in the abdomen-not necessarily at the stomach-is
quickly followed by retching and vomiting; the patient lies absolutely
quiet, with the legs drawn up, and refuses to make the slightest effort
or motion, refraining even from speaking, and attempting to suppress
breathing; the countenance is pale, and expresses intense suffering;
the pulse is quick, small, compressible; tongue dry; thirst usually
intense; the abdomen is excessively tender to the slightest pressure;
the patient dies in collapse or, after a brief temporary improvement
of the symptoms, from peritonitis.
Abscess in the Walls of the Stomach is of very rare occurrence.
The walls of the stomach may be the seat of cancerous inflammation,
resulting in the formation of pus, which finds its way through the
mucous membrane; fibroid thickening of the walls may lead to the
same result; still more rarely, the submucous tissue becomes the seat
of general suppuration, practically being a gastritis. Death generally
results from pyæmia. The symptoms characteristic of this condition
are not well defined, although Dr. Brinton gives a somewhat exhaus-
tive description, bearing close resemblance to the symptoms of a vio-
lent gastritis, accompanied with a tympanitis which differs from that
of general peritonitis by being limited to the epigastrium. The disease,
in the course of a few days, progresses to a fatal termination, preceded
by a profound prostration and delirium.
Rupture of the Stomach is usually the result of an external in-
DISEASES OF THE ORGANS OF DIGESTION.
683
jury received, especially at a time when the stomach is distended by
food. Ziemssen states that he has seen it occur from distension de-
pending upon fermentation in a stomach which was the seat of strict-
ure resulting from the healing of a chronic ulcer; the symptoms were
those of collapse, followed by peritonitis.
Albuminoid Disease of the Stomach, also described as Waxy,
or Lardaceous, Disease of the Stomach, has been mentioned in con-
nection with chronic gastric catarrh, in the course of which it occurs ;
it usually coexists with similar structural changes in the liver, spleen,
or kidney. During life it cannot be recognized, owing to the absence.
of characteristic symptoms. Examination after death shows a pale
and bloodless condition of the membrane, which gives a peculiar and
well-known brownish-red reaction when treated with iodine; there is
found a destruction of the epithelial cells, and their complete conver-
sion into an irregular, homogeneous mass.
Wilson
Tubercle of the Stomach is of very rare occurrence.
Fox states that he never saw it commence in the mucous membrane,
but that he has found perforation of the stomach from tubercles which
commenced in the peritoneum, passing from without inwards, in ac-
cordance with the recognized tendency of tubercles seated anywhere on
the peritoneal surface. Bignon reports a case of perforation of the
stomach by a tubercular ulcer which commenced in the submucous
tissue of the great curvature; the ulcerative process had invaded the
gastro-epiploic artery, causing copious bleeding; the ulcer was sur-
rounded by tubercles.
The rarity of this affection is amply shown from statistics. Willigk
observed it only five times in 1317 cases. Barthez and Rilliet state
that the seat of tubercle of the stomach is usually in the great curva-
ture, and that it may be associated with extensive ulceration.
D. DISEASES OF THE INTESTINES.
ENTERALGIA.
BY A. C. COWPERTHWAITE, M.D., PH.D.
Definition. A neuralgic affection of the intestines, which is char-
acterized by paroxysms of intense, sharp pain, lacking the griping and
twisting nature of colic pain, from which it is often distinguished with
much difficulty.
Etiology. A nervous diathesis is the most important predisposing
element, but, as in colic, we find that age and sex exert an important
ætiological relation. The disease is most likely to occur during adult
age, and especially in women, in whom it is often associated with
ovarian and uterine disorders and hysterical conditions. In general,
684
A SYSTEM OF MEDICINE.
it may be said that all those predisposing elements which tend to
produce neuralgic conditions elsewhere, are equally potent here.
Enteralgia is strictly a visceral neuralgia, and the same character of
constitutional causes are required to produce it, which are capable of
producing any other form of neuralgia. Heredity is an important
factor. The various dyscrasiæ, such as malaria and syphilis, are un-
doubtedly causative. Any condition of lowered vitality or a depressed
state of the bodily functions, anæmia, neurasthenia, or the exhaustion
of nerve force induced by sexual excess, and gouty rheumatic condi-
tions, are predisposing causes. So also weakness, resulting from acute,
or more especially from long-lasting, chronic diseases, by impairing
the tone of the nervous system predisposes to enteralgia. Especially
is this the case in those affections in which there is, or has been, a
continued loss of the vital fluid, as in menorrhagia and other hæmor-
rhages, or when there has been excessive lactation or a prolonged.
lochial discharge, or a profuse leucorrhoea, or any wasting discharge.
In short, anything tending to deteriorate the blood, and to depress the
nervous system, may produce enteralgia.
Enteralgia is frequently of reflex origin, as when it occurs in con-
nection with hysteria. Its occasional association with caries of the
vertebræ and affections of the spinal cord also serves to establish its
reflex origin. This may also be a factor in its connection with Bright's
disease and other structural lesions, but it is more than probable that
the contamination and alteration of the blood in these pathological
states is sufficient to account for the tendency to neuralgic disturbance
often found associated therewith.
Indigestion and constipation may excite an attack of enteralgia.
The use of indigestible food, or conditions of the system which cause
a partial failure of the digestive processes, or the presence of impacted
fæces, or flatulence, may produce a neuralgic condition; but these cases
partake largely of the character of an intestinal colic, and should be dis-
tinguished from enteralgia.
Lead Colic, also known as painter's colic, plumber's colic, colic of
Poitou, and colica pictorum, is distinctly a neuralgic affection, and
should be so considered. It is caused by the absorption of lead into the
system, and occurs amongst painters, plumbers, white-lead makers, and
lead-paint manufacturers, type-founders, compositors, and others who
work in an atmosphere which is loaded with particles of lead. In a
comparatively rare number of cases lead colic is caused by ingesting
food or drink containing lead, or by using medicinal preparations of
lead.
Speaking of the manner of the introduction of lead into the system,
Dr. Flint says that it may take place through the lungs, the stomach,
* Vide A Treatise on the Principles and Practice of Medicine, by Austin Flint,
M.D., page 478.
DISEASES OF THE ORGANS OF DIGESTION.
685
the mucous membrane in other parts, and the skin. Certain occupa-
tions involve the inhalation of lead. Persons employed in the manu-
facture of lead-paints are not exposed, and, of those who suffer from
lead-poisoning, the largest proportion are of this occupation. Next to
this class, painters are most exposed. More or less exposure, by in-
halation, belongs to a great number of occupations, such as paper-
staining, grinding of colors, glazing cards, manufacturing earthen pot-
tery, plumbing, shot-making, etc. Lead poisoning has frequently
occurred from sleeping in newly painted rooms. Lead may be intro-
duced into the stomach through various articles of food or drink. The
colic of Poitou was due to wine, and that of Devonshire to cider adul-
terated with lead in order to give it sweetness. This kind of adultera-
tion has been practiced since the occurrence of the affection in the
places just named, and it is perhaps yet resorted to. Liquid and
solid articles of diet, especially if they contain a free acid, become im-
pregnated with lead by being in leaden vessels, or earthen vessels
glazed with lead. Some years ago, a large number of persons within
a limited district in Ohio were affected with a disease which, for some
time, was regarded as a novel epidemic, and received the name of dry
cholera. It was found to have the diagnostic character of lead colic,
and was traced to the common use of a cheap kind of earthenware
made in that vicinity, into the glazing of which lead entered. Prof.
Fenner, in the Southern Medical Reports, vol. i., describes an epidemic
colic which he observed in New Orleans, and which he traced to lead
contained in soda water; and Prof. Doremus, some years ago, demon-
strated the presence of lead in considerable quantity in the soda water
drawn from fountains in New York City. Water distributed in lead
pipes is not unfrequently the vehicle of its introduction into the system.
Lead sometimes enters into the substances used in coloring confec-
tionery, condiments, and other articles, in sufficient quantity to give
rise to poisonous effects. Articles inclosed in lead-foil may become
contaminated. Authentic instances of poisoning by the use of tobacco
thus inclosed have been reported. The habit of chewing shot and
pieces of the lining of tea boxes has been known to give rise to various
manifestations of lead-poisoning, lasting for four years before the cause
of disease was discovered. During the spring of 1866, two hundred
and thirteen cases of lead-poisoning occurred in the Walkill Valley,
Orange County, New York. After considerable research, it was ascer-
tained that lead was contained in the flour and meal used in that part
of the country. The source of lead was found to be the stones used
for grinding the flour and meal. The stones were old, constantly
needing repair, large cavities frequently occurring, which were filled
with common lead instead of cement. The attrition of the grinding
detached minute particles of lead, which, becoming mixed with the
flour and meal, was transformed into the carbonate by the processes
686
A SYSTEM OF MEDICINE.
of fermentation and baking. These are only a few of the divers modes
in which lead finds its way into the alimentary canal. Its use as a
remedy has given rise to colic and other morbid affections. It may
be introduced through the skin, although, doubtless, with difficulty.
Prof. Lewis Rogers, of Louisville, says that he has known the charac-
teristic paralysis, called wrist-drop, fairly attributable to the long-con-
tinued application to the face and hands of a cosmetic containing
lead; and Prof. Sayre has reported a case in which this manifesta-
tion of lead-poisoning followed the use of the article known as
Bloom of Youth. Finally, instances of lead-poisoning by means of
collyria and vaginal injections have been reported. Some persons
are especially susceptible to lead-poisoning, owing to an idiosyn-
crasy. Persons who have once suffered from it are liable to future
attacks.
Pathology. The impairment of the vital fluid promotes enteralgia;
this is especially the case when the intestinal tract becomes deficient
in tone, and the peripheral extremities of the nerves become morbidly
sensitive, so that slight causes produce pain, the presence of an offend-
ing substance in the bowels, or a distension by an accumulation of
gas, being a sufficient causation. We have also mentioned the rela-
tions probably existing between various morbid states which induce
structural lesion, and the neuralgia so apt to be associated with them.
The blood in these cases becomes poisoned through the influence of
the organic disease, and the cerebro-spinal and organic centres are
secondarily affected.
When enteralgia results from malaria, and other similar blood-states,
the nerve centres become secondarily influenced and transmit this in-
fluence to the affected part. When we come to a study of the anatomo-
pathological changes induced by enteralgia, we are made painfully
aware of our lack of reliable information upon this subject, and of the
great difficulty of discovering the essential nature of the disease. It
is comparatively easy to understand how a hyperemia may produce
irritation and reflex phenomena, and that this condition is most likely
to exist at the origin of the nerve rather than along its course. It is,
however, true that the nerves themselves are sometimes involved in
this hyperæmic state, even to the extent of inflammation, enlarge-
ment, and softening or induration, the neurilemma being the part
mostly affected. This fact has led some pathologists to hold that a
slight neuritis is at the bottom of all neuralgias-a proposition not to
be disproved by merely negative testimony. But when we consider
that in a large majority of cases the most careful investigations have
failed to discover any changes whatever, we must conclude with Anstie
that the various pathological conditions found in connection with
neuralgic states, have been simply accidental, and are rarely to be
regarded as the effect or cause of the disease. At all events, Dr. Erb
DISEASES OF THE ORGANS OF DIGESTION.
687
is correct in the statement that the pathogeny of neuralgia is still ex-
tremely obscure, and for the most part rests on hypothesis.
((
Symptomatology.-Romberg describes enteralgia as follows:
There are attacks of pain spreading from the navel over the abdomen,
alternating with intervals of ease. The pain is tearing, cutting, press-
ing, most frequently twisting, pinching, introduced and accompanied
by peculiar bearing-down pains. The patient is restless, and seeks
relief in changing his position and in compressing the abdomen; hist
hands, feet, and cheeks are cold; his features are pinched, the wrinkled
brows and contracted lips betray his agony. The pulse is small and
hard. The skin of the abdomen is tense, whether puffed up or drawn
inward. There are often nausea, vomiting, and desire for stool. Some-
times there is also tenesmus. There is usually constipation, but some-
times the bowels are regular, or even too loose. Such an attack may
last from a few minutes to several hours, relaxing at intervals. It
ceases suddenly as if cut off short, and there is a feeling of the greatest
relief. The course is periodical, but less regularly so than in other
neuralgias."
When enteralgia occurs in connection with other diseases, it may
only be considered as a symptom, and its characteristics are modified
according to the nature of the affection which has produced it. So
does the duration of the disease vary, according to the nature of its
fundamental cause, from a few minutes to several hours, or days, some-
times ceasing with a single paroxysm, and again continuing with more
or less regular intervals for an indefinite period.
In lead-colic the symptoms are usually developed gradually, being
preceded by, or coincident with, symptoms of lead-poisoning. The
patient is anæmic, the skin looks dirty and earthy, the gums are dark,
the teeth discolored, the breath fetid, and the patient complains of a
sweetish, metallic taste in the mouth. The discoloration of the gums
is an important indication, and occurs in a large majority of cases.
It appears on the gums at their junction with the teeth, and is of a
blue or slate-gray color. It not only occurs before the attack, but
usually remains during the continuance, and even after the cessation
of the disease. The pain is at first slight, and extends from the epi-
gastric or the umbilical region around to the back and extremities.
This gradually increases, and, though at first dull, often becomes acute
and lancinating in its character, the patient uttering loud groans and
cries, and assuming various unnatural and often absurd positions.
The abdomen becomes retracted, hard, and resisting, from tonic con-
traction of the abdominal muscles; the pulse becomes slow, the voice
hoarse, the skin cool; nausea, vomiting and hiccough are not uncom-
mon; strangury may occur; the mind is anxious and depressed.
There is almost always obstinate constipation, with stools consisting
of small, hard lumps or round balls. In exceptional cases the abdo-
688
A SYSTEM OF MEDICINE.
men is tympanitic, and pressure causes an intense aggravation, but
usually the retraction, which is considered pathognomonic, is present,
and hard pressure temporarily relieves the suffering, though light
pressure may aggravate it. Often there is found a coexisting paraly-
sis of the exterior muscles of the forearm, known as "wrist-drop." The
course of the disease presents a remittent type, the paroxysms giving
way to more or less lengthy intervals of comparative ease, the patient
being at times entirely free from pain; usually, the pain does not
entirely disappear. The duration of the attacks varies, sometimes
lasting only a few hours, never to recur, while in others relapses
at irregular intervals are prone to occur, and may continue for an
indefinite period.
Diagnosis.—The symptoms of enteralgia are so characteristic that
it is not usually difficult to distinguish it from other affections. It
may be confounded with intestinal colic, but if we bear in mind the
causes, and take into consideration the constitutional, predisposing
elements which may be present, an error should not often be made.
Many authors make no distinction between enteralgia and intestinal
colic, and since the treatment is in most cases essentially the same, a
mistake in the diagnosis might not be a serious matter. It is safe to
say that the causes of enteralgia are usually of centric origin, while
those of colic are more likely to be local or peripheral. The pains are
more darting than those of colic, and partake less of the griping or
twisting character.
Enteralgia is easily distinguished from enteritis and other inflam-
matory affections by the absence of the local and general signs of in-
flammation. The pulse remains unaltered, the skin cool, the tongue
moist, there is no thirst, the bowels are constipated, the abdomen, if
distended by flatulence, is not sensitive, and pressure may even per-
ceptibly relieve the suffering; the pain moves about from place to
place, while in inflammation it is stationary.-When the attack is due
to lead-poisoning, the symptoms are remarkably pronounced and can
not be mistaken.
Prognosis. The prognosis is always favorable, and even the most
inveterate cases of lead colic do not prove fatal. When a patient dies,
presumably from enteralgia, it will be found that this condition was
only secondary to some structural disease which had been overlooked
during life.
Treatment. The preventive treatment of enteralgia consists in
applying such measures as would tend to remove the predisposition
of the system to neuralgic affections. The use of nourishing food,
together with proper exercise and an abundance of sunlight, the pro-
scription of all excesses, especially sexual, and the adoption of the
usual methods for the restoration of the tone and vigor of the system,
are essential. In cases of lead-colic the continued exposure to the
DISEASES OF THE ORGANS OF DIGESTION.
689
poison must be avoided, even if the patient be compelled to suspend
his occupation. If the source of the poisoning be obscure, it should
be sought for until found and removed. Persons obliged to work in
an atmosphere charged with lead may do much to ward off lead-poi-
soning by having the apartments well ventilated, bathing the body
frequently, and carefully cleaning the mouth and teeth. Such per-
sons should employ a diet of fruit and vegetables, with oatmeal and
Graham flour, in order to keep the bowels in a healthy condition with-
out the aid of purgatives. Drinking largely of milk or, it is asserted
by others, the use of Sulphuric acid acts as a prophylactic and antidote
in lead-colic. A drachm of dilute Sulphuric acid in a quart of sweet-
ened water may be taken in the course of twenty-four hours. A nour-
ishing diet is of the utmost importance, and animal fats are especially
desirable.
Persons suffering with enteralgia should be well protected from cold
and atmospheric changes by dressing warmly, wearing flannel next
the skin, throughout the year. Rest is of the utmost importance, and
should be strictly enforced as an essential condition of a permanent
cure.
Therapeutics. —Nux vomica.—Enteralgia arising from indigestion or from
over-eating; in persons of sedentary habits, or in those who dissipate; hypochondri-
acal mood; over-sensitive; great dread of and incapacity for literary work; irresisti-
ble sleepiness during the day, especially after meals, but wakefulness at night; pains
periodical after breakfast, or after meals; relief from bending double; constipation ;
characteristic headache.
Colocynth.-Enteralgia from cold, or from excessive use of fruit. Pains occur
in paroxysms; contractive, twisting, griping, cutting pains, mostly about the umbili-
cus; has to bend double, being worse in any other position; better by pressing some
hard substance against the abdomen; great restlessness, and loud screaming on chang-
ing position; relief from coffee and smoking tobacco, and from the passage of flatus;
other food and drink aggravates.
Dioscorea.-Constant dull, heavy, or cutting, griping, twisting pains in the
abdomen, which do not intermit, and are relieved by stretching the body out or by
walking about, being aggravated by rest. The pains in the abdomen suddenly shift
and appear in distant localities, as in the fingers and toes; hyperesthesia of the ab-
dominal nerves. Stools dark-colored, bilious, very offensive; constant, ineffectual
desire to go to stool.
Arsenicum.-Due to malarial influences, or some constitutional cachexia, or
organic disease; also in cases coming on suddenly from drinking ice-water or eating
ice-cream. Violent, periodical burning or cutting pains, with intolerable anguish and
restlessness; great weakness and prostration, the strength suddenly sinking. Pains
usually worse at night, after eating and drinking, and better from warm applications;
nausea, vomiting, and dark-colored, watery, offensive diarrhea; sometimes constipa-
tion.
Belladonna.-Sensation as if a spot in the abdomen were seized with the nails,
a griping, clutching, clawing pain; violent, cutting pressure in abdomen, now here, now
there; the pain comes on and disappears suddenly; tenderness to slight pressure, but re-
lieved by hard pressure across the abdomen; worse after 3 P.M., and after midnight;
tendency to cerebral congestion; thirst, but drinks little, as drinking aggravates.
Chamomilla.-Peripheric neuralgia; griping, tearing pain in region of navel,
and lower down on both sides, with pain in small of back as if broken; flatulence ;
the abdomen is distended like a drum; flatus passes in small quantities, without re-
lief; better from warm applications; sensation as if the bowels were drawn up in a
VOL. I.-44
690
A SYSTEM OF MEDICINE.
ball, and as if the whole abdomen were empty; pains appear at night or in the morn-
ing after eating, or from anger.
Alumina.-Lead colic. Spasmodic pains in hypochondria and stomach, with
dyspnoea, or passing down in the groins, like hernia.
Cinchona.-Enteralgia from malaria, from sexual exhaustion, loss of vital
fluids, or from the passage of gall-stones. Pain in hepatic region as from subcutaneous
ulceration, worse from touch; violent, pinching pain, relieved by bending double,
returning every afternoon or at night; tympanitic distension of the abdomen.
Coffea.-Excessive pains as if the abdomen would burst, driving to desperation ;
great nervousness; suffocative fits; convulsions.
Cuprum.-Violent intermittent, cutting, drawing pains; cramps in the abdo-
men; abdomen drawn in and sore to the touch; spasmodic movements of the abdomi-
nal muscles; restless tossing about and great uneasiness, with piercing screams; ag-
gravated by drinking cold water.
Opium.-Lead colic. Violent griping and cutting in the abdomen; pressive
pain as if the intestines would be cut to pieces; abdomen hard and distended; consti-
pation from inactivity of the bowels, and from spasmodic retention in the small intes-
tines; retention of urine.
Platina.-Lead colic. Pressing, bearing-down pain in abdomen, extending into
the pelvis; the patient screams, and tries to relieve the pain by turning in all possible
positions.
Plumbum.-Excruciating pains in umbilical region, shooting to other portions
of the abdomen and body, somewhat relieved by pressure; abdomen retracted to the
spine, as if drawn in by a string; recti muscles hard and knotty; better from rubbing or
hard pressure; obstinate constipation.
Consult Aconite, Asa f., Cocculus, Colch., Ignatia, Iris vers., Lycop., Merc.,
Phos., Puls., Rhus tox., Sepia, Stannum, Verat. alb., Zinc.
Of the auxiliary measures, warm bathing is the most important.
A hot mustard foot-bath sometimes is of considerable service.
Hot fomentations and a copious enema of warm or hot water fre-
quently give immediate relief.
In cases where the pain is violent, and relief is not obtained from
the remedies given, Chloroform may be administered internally, and
also applied externally, either alone or combined with Laudanum. If
this still fails to relieve, recourse should be had to the hypodermic
use of Morphia.
ENTERITIS.
BY A. C. COWPERTHWAITE, M.D., PH.D.
The term Enteritis is, by custom, limited to the designation of a
catarrhal or croupous inflammation of the mucous membrane of the
small intestines; yet, it technically covers all forms of inflammation
of the bowels, including that which affects only the serous and mus-
cular coats as well as that which involves the entire thickness of the
intestine. Inflammation of the duodenum and of the cæcum and its
appendix are so liable to occur as separate affections that they are not
usually included in the term enteritis, and will be separately con-
sidered. That form of inflammation which affects the serous and
muscular coats of the intestines, rarely occurs idiopathically, but
usually as an extension of a peritoneal inflammation, or, less often,
DISEASES OF THE ORGANS OF DIGESTION.
691
the muscular coat and its connective tissue become involved in the
inflammation originating primarily in the mucous membrane. It
offers no special pathological features nor diagnostic peculiarities other
than those belonging to the primary lesion with which it is associated.
It is rarely recognized during life, nor does post-mortem examination
usually reveal its existence.
Varieties and Etiology.-Inflammation of the mucous sur-
face of the intestines rarely occurs after infancy, though it may be
met with in persons of all ages. This could not be said were we to
assume that all cases of diarrhoea were not to be distinguished from
true catarrhal inflammation, as functional diarrhoea may be said to
occur with comparative frequency in all ages, though infants are more
prone to intestinal disorders, especially inflammation and diarrhoea,
than are adults. Catarrhal inflammation is ordinarily due to some
direct irritation of the mucous lining by food or other materials, such
as alcoholic liquors, acid poisons, and drastic purgatives, or to the ef
fect of a cold; it is also frequently associated with various exanthem-
ata, and with dentition. It arises also from reflex disturbance due to
causes not readily discovered. Another variety of catarrhal inflam-
mation of the intestines occurs only during infancy, and is called en-
teritis folliculosa, or entero-colitis. It is chiefly a summer malady, at-
taining its maximum prevalence and mortality in July and August,
when the temperature is at its highest. It is not, however, the heat
alone which produces the disease, for it thrives best in large cities, on
newly made ground, and in low and swampy localities. In the coun-
try, on high ground, it is scarcely known. Hence it is supposed that
noxious inhalations from various sources, mostly from vegetable and
animal decomposition, which arise as a consequence of the heat, com-
bine with the latter and form the exciting cause.
Bottle-fed in-
Errors of diet are essential causes of entero-colitis.
fants rarely escape its effects, and even nursing infants who are allowed
to have improper articles of food more or less regularly are inclined to
the disease. It also frequently follows weaning. In my own experi-
ence, infants who are nursed at the breast and properly cared for rarely
have this disease, or, if they have it, the attack is usually mild and
easily controlled. Teething children are especially liable to this dis-
ease, but it is a question whether, or not, dentition is in itself an ex-
citing cause, it being usually presumed that the diarrhoea, occurring
during that period, is entirely non-inflammatory. My own experi-
ence leads me to believe that dentition is a distinct cause of enteritis
folliculosa, though, of course, more liable to produce it when assisted
by the other causes before mentioned. Entero-colitis may also be
produced by exposure to cold, especially during sudden changes of
temperature in summer.
Croupous inflammation occurs mostly during adult life, and rarely
692
A SYSTEM OF MEDICINE.
in childhood or after forty-five. It is most likely to occur in nervous,
hysterical, or hypochondriacal persons, especially women. It is sup-
posed to be caused by the same agencies that may cause catarrhal in-
flammations, especially those which produce direct irritation of the
mucous membrane. Such, however, can only act as exciting causes,
for in true croupous inflammation a favorable condition of the system
must exist for its propagation. True diphtheritic enteritis may occur
by extension of the diphtheritic process downwards, and then consti-
tutes a specific disease, due to specific causes. Membranous forma-
tions may also occur in the early days of dysentery, but they are quite
distinct from the non-contagious croupous inflammation of the intes-
tines. That form of enteritis which involves the entire structure of
the bowels, and for which there is no distinguishing term, is rarely a
primary disease, and is most often met as associated with strangulated
hernia and intussusception, resulting mainly from distinct mechanical
causes, interfering with the intestinal circulation or producing direct.
injury to the coats of the bowels, as by the presence of impacted fæces
or the passage of gall-stones. It may also result from an extension of
peritoneal inflammation.
Pathology. In the milder forms of catarrhal inflammation we
find only the ordinary evidence of catarrh as it occurs in other mucous
membranes, being a slight redness and tumefaction, with more or less
mucous coating. This may proceed in intensity to complete conges-
tion, the membrane becoming softened and thickened, the process in-
volving, not unfrequently, the submucous tissue. The secretions are
abundant, ropy or watery in appearance, and often very irritating, and
are sometimes mixed with blood. Superficial erosions or slight ulcera-
tions are not uncommonly observed. In the croupous variety there.
is a greater intensity of the inflammatory process, and a membranous
or diphtheritic deposit is found over the surface, mostly of the ileum.
and colon, being of a white or grayish-white color, and firmly ad-
herent. It consists of corpuscular elements, granules, free nuclei and
small, shrivelled, irregular, and rather granular cells, cemented to-
gether by a coagulable exudation, and prolonged for the most part
by rootlets from its under surface into the Lieberkühnian follicles.
Chemically, these masses are said to have the same reaction as mucus,
as might be inferred from the results of the microscopical analysis.
The pathological anatomy of enteritis folliculosa is nowhere so graphi-
cally described as by Vogel in his masterly description of that disease.
"The submucous tissue is found markedly infiltrated, so that the
bowel has perceptibly increased in weight, and the signs of an acute
intestinal catarrh are present upon the entire mucous membrane of
the large, and upon an extensive tract of the small, intestines, i. e., in-
stead of the normal cylindrical epithelium, none but mucous corpus-
cles are seen. The solitary glands and Peyer's patches are in some
DISEASES OF THE ORGANS OF DIGESTION.
693
parts intensely swollen, and at the first glance are seen to project, like
white nodules, above the level of the mucous membrane; in other
parts, however, they are already ruptured, and then represent empty,
minute, crater-like excavations. These excavations occur upon the
summits of the elevations originally produced by the swelling of the
follicles. The mesentery is injected and turgid, the chylopoetic ves-
sels are plethoric and of a pink color, the mesenteric glands in those
regions corresponding to the intestinal catarrh are increased in size
from two to four fold; in recent cases, when cut into, the incised surface
presents a rose color, but when of longer duration a yellowish-white
color. The microscopic elements are the same as in normal mesenteric
glands, but when the color is yellowish, and the gland is increased in
hardness, the connective tissue will be found to predominate. Here,
too, as in simple intestinal catarrh, notwithstanding the long existence
of the diarrhoea, remarkably little pigmentation of the mucous mem-
brane is found. The essential anatomo-pathological difference be-
tween intestinal catarrh and enteritis folliculosa consists in the cir-
cumstance that in the latter the mesenteric glands participate in the
disease. It is much to be regretted that neither by injection nor any
other manner can it be experimentally proven that the absorption of
the chyle is hindered by these hypertrophied mesenteric glands, and
thereby the nutrition and progressive development of the child inter-
fered with. But when in an atrophied child whose condition was
originally introduced by enteritis folliculosa no changes but those in-
durated and hypertrophied mesenteric glands are found, the supposi-
tion becomes very probable that the passage of the chyle has been
mechanically interrupted, and thus the children, although they have
consumed an enormous quantity of food, and have had no diarrhœa
for weeks preceding death, have, nevertheless, languished to a certain
extent for want of a sufficient supply of chyle. The term tabes mes-
enterica of the older physicians is, therefore, by no means so incor-
rectly founded and obsolete as some of the later writers are inclined
to represent. The older erred only in this, that they thought they
could feel the enlarged glands. In this glandular hypertrophy the in-
testines always become tympanitic and distended, and then it is alto-
gether impossible to feel these small tumors, which scarcely ever attain
to the size of a hazel-nut, between or beneath the tense bowels. At
any rate, they must be forcibly compressed against the vertebral
column, if it is desired to feel them. In instances of developed tuber-
culosis of the mesenteric glands, as it sometimes occurs in children sev-
eral years old, the firm, hard, solitary tubercles may indeed be felt
through the abdominal walls. But these are larger glands agglomer-
ated into patches or masses, and traversed by deposits of cheesy tuber-
cle. Such slight enlargement as is observed in enteritis folliculosa
can never be detected during life by the sense of touch."
694
A SYSTEM OF MEDICINE.
If the entire structure of the intestine is involved, we find the
affected part, which is usually in the small intestine, much dilated,
while the external or serous covering presents a dark purplish appear-
ance, dotted here and there with patches of superficial congestions or
extravasations, more or less covered with an exudation of lymph.
The mucous and submucous tissues present a similar, though more
intensified, condition, the color being often nearly black, and the
tissues soft and swollen, emitting an offensive, gangrenous odor.
Frequently the mucous surface will present instead a pale appear-
ance, the lymph-exudation being more or less mixed with pus, but
having the same offensive odor. The intestine below the inflamma-
tion is found contracted and empty, save a little sanguineous exuda-
tion, while above it is usually dilated and full of fecal matter, with
more or less of the sanguineous exudation. More or less ulceration
may follow these forms of inflammation. Especially is this the case.
after chronic catarrhal inflammation. The dark red and swollen
mucous membrane softens and is destroyed by suppuration in its.
tissue; the result is a loss of substance which exposes the submucous.
or muscular tissue. If the ulcer heal at this stage, the loss of sub-
stance is filled with granulations, and a firm cicatrix remains which
almost always constricts the intestine. In other cases the muscular
and serous coats are always destroyed and the intestine perforated,
while the destruction proceeds from within outward; a partial peri-
tonitis may occur, and cause a union with neighboring portions of
intestine, thus preventing the escape of the contents of the bowels
into the abdomen (Niemeyer). Follicular ulceration may follow ulcer-
ation. It is destructive in its character, and occurs almost exclusively
in the large intestines.
Rokitansky states that at first the follicles are greatly swollen and
surrounded by a dark-red, vascular ring; subsequently they ulcerate
from within, and the pus breaks through; there is a small follicular
abscess, which has red, spongy walls, and a small ulcerated, firmly-
fringed opening. While the ulceration gradually destroys the whole
follicle, the hyperæmia of the adjacent mucous membrane gradually
disappears; the ulcer is then about the size of a lentil seed, round or
oval. The ulceration soon extends to the surrounding mucous mem-
brane; the round form of the ulcer is lost; large, irregular ulcerations
occur, or, for a considerable distance of the intestine, some islands
and irregular projections of the membrane are preserved, while else-
where the submucous or the muscular tissue is exposed. In the intes-
tines we usually find a grayish-red, half-fluid floccular substance,
mixed with undigested ingesta.
Bristowe* says that the changes which take place in chronic enteritis
consist generally in slight condensation and hardening of the mucous
* Reynolds's System of Medicine, vol. iii., p. 162.
DISEASES OF THE ORGANS OF DIGESTION.
695
tissue, more or less distinct congestion, or black pigmentary deposit
in the villi and interfollicular spaces, some degree of atrophy of the
Lieberkühnian follicles, and granular or fatty degeneration of their
epithelial contents, together with an analogous condition, more or less.
pronounced, of the epithelium of the mucous surface generally. The
solitary and agminated glands are sometimes atrophied, sometimes
larger and more obvious than natural. The changes indeed are
chiefly changes of degeneration, and in that sense, as probably also
clinically, are related to the lardaceous degeneration which occasion-
ally happens in persons laboring under chronic tuberculosis, or bone-
disease attended with suppuration and secondary syphilis. Larda-
ceous degeneration occurs later in the bowel, and then in the liver,
spleen, and kidneys; it is found chiefly in the lower part of the ileum
and the large intestine; it affects, in the first instance, the small
arteries and capillaries around, and in the solitary and agminated
glands, which bodies become swollen, and then gradually tends to
involve the whole thickness of the intestinal wall, the muscular fibres
and other tissues becoming finally infiltrated. The bowel thus becomes
thickened, and at the same time harder than natural, and often, in the
later stages, erosion of the affected glands occurs, leading in Peyer's
patches to a reticulated condition of surface. The above chronic affec-
tions of the mucous membrane are generally associated with diseased
conditions of other organs, to which indeed they are secondary, and
not unfrequently the stomach at the same time is the seat of some
chronic morbid process. The presence of these complications, and
the fact that, clinically, ulceration of the bowels, together with tuber-
cular and other morbid processes, passes in a large number of cases
for chronic inflammation, render it difficult to isolate the clinical
phenomena due especially to the bowel affections now under considera-
tion. They doubtless vary greatly, but may be briefly summarized
as containing in various proportions both relatively and positively
imperfect digestion of the alimentary matters received into the intes-
tines, excessive secretion of more or less watery mucus, increased
peristaltic movements with griping pains, looseness of bowels, with
discharge of watery or yeasty, or otherwise unhealthy and offensive,
evacuations, and innutrition from the imperfect absorption of food.
Symptomatology.-Catarrhal inflammation is usually charac-
terized by pain and tenderness over the abdomen, which is especially
aggravated by hard pressure, also diarrhoea, and sometimes nausea
and vomiting. The pains are mostly colicky and griping in their
character, and occur chiefly in the umbilical region. Diarrhoea is not
always, but usually, present, is accompanied by great rumbling, and
is aggravated by taking food or drink; the stools are more or less
frequent, being at first feculent, but soon assuming a watery, gelatin-
ous character, and becoming very irritating. Tenesmus is not present,
696
A SYSTEM OF MEDICINE.
unless the lower part of the large intestine is involved in the inflam-
matory process. There is usually considerable febrile disturbance,
though this may not seem in proportion to the severity of the attack.
The patient complains of headache, languor, aching in the limbs,
more or less chilliness, with increased pulse, these symptoms show-
ing the usual peculiarities of an ordinary catarrhal fever. The tongue
is generally dry and furred, the breath offensive, and the appetite
impaired.
If the disease be confined to the rectum, as is sometimes the case,
there is a constant desire to go to stool, the passages are mucous, or
consist of bloody mucus without any fæces, but there are none of the
characteristic pains in the abdomen which are present when the
ileum and colon are involved.
The symptoms of croupous inflammation may differ only in degree
and gravity from those of the catarrhal variety, or may assume an
entirely different form, and cannot be said to preserve any character-
istic identity. The patient presents no appearance of fever, but seems
depressed in both body and mind. He first complains of soreness in
the abdomen, which is more or less distended, and there is obstinate
constipation. Severe colicky pains, especially about the navel, occur
in repeated paroxysms for several hours, and finally subside leaving
the abdomen sore and very sensitive to pressure, the absence of fever
only distinguishing it from the first stages of peritonitis.
Diarrhoeic stools may now occur, containing considerable mucus,
and accompanied by much tenesmus. This lasts for a day or two,
when the tenesmus becomes very violent, and after great straining
shreds of membrane are discharged, and sometimes cylindrical casts.
of the bowel. This is followed by great relief, and the patient feels well,
save the extraordinary debility, emaciation, and great weariness and
languor. Usually these attacks are repeated from a few days to sev-
eral weeks apart, and may continue until the patient finally dies from
exhaustion. Sometimes long intervals of comparative health may
At other
occur, and then the attacks return with renewed violence.
times the paroxysms are less acute, and continue at more or less reg-
ular intervals for months and, sometimes, years. The patient usually
suffers during the intervals with all the symptoms of disturbed diges-
tion and defective nutrition. The head aches almost continually, the
mind is impaired and much depressed, and in women the sexual
system is deranged and subject to various discases, hysteria being
nearly always present. Such may be the course of croupous enteritis,
subject to many variations which it would be useless to enumerate.
In enteritis folliculosa the symptoms are at first those of catarrhal
inflammation. The stools are especially foul and irritating in their
character, and have a greenish color; the fever is more intense; vomit-
ing is very free; the tongue is red and smooth, or covered with a
DISEASES OF THE ORGANS OF DIGESTION.
697
white fur, and an aphthous condition of the tongue and buccal cavity
usually exists. The child emaciates rapidly, and becomes very flabby
and relaxed; the fat and muscles disappear and the skin becomes
wrinkled, giving the child a remarkably aged appearance.
The inguinal glands become enlarged, the eyes sunken, the abdo-
men tympanitic, and the child dies from exhaustion or from the super-
vention of cerebral complications, as convulsions or coma. Both the
catarrhal and croupous varieties of enteritis usually run a brief course,
convalescence being declared in a week or ten days. Sometimes, how-
ever, they lead to persistent modifications of the mucous membrane,
and there is present chronic intestinal catarrh or chronic enteritis.
Here the symptoms frequently differ little from those of acute en-
teritis, save that they are both milder and more persistent. Often no
other symptom than a chronic diarrhoea is present, the stools being
liquid, pale, fermented, and very offensive or lienteric, varying much
in number and quantity. In many cases uneasy, griping sensations
and gurgling are experienced from time to time, or there may be some
degree of soreness over the abdomen. Gastric symptoms are gener-
ally present, and the tongue often presents an abnormal character.
Owing to interference with digestion and nutrition, more or less atrophy
is usually present, and a slight pyrexia, especially toward evening, is
often observed. Sometimes chronic inflammation is not accompanied
by diarrhoea, and the patients are constipated. In such cases the
patient generally suffers more from disturbance of other organs. The
abdomen becomes distended with flatus which, having no outlet,
presses upon the diaphragm, impairs respiration, and by compression
of the arteries causes congestion of other organs, more especially of
the brain, giving rise to nervous and mental disturbance, the patient
being morose, irritable, and inclined to think and talk only of him-
self and his sufferings. Chronic enteritis may become associated with
ulcerations or amyloid or lardaceous degeneration.
In inflammation of the entire thickness of the bowel the symptoms
are essentially distinct from those already described. They may creep
on slowly and insidiously, or be manifested suddenly and with great
intensity. The pain is severe, and is greatly aggravated on pressure
and by motion, and is associated with colic, tormina, obstinate con-
stipation, nausea and vomiting, intense thirst, furred tongue, marked
febrile disturbance, and a distressed, anxious expression of coun-
tenance.
After a time the abdomen becomes tympanitic, while the painful
sensations subside in a measure, even to complete cessation. The con-
stipation and vomiting continue, the latter gradually becomes sterco-
raceous, hiccough sets in, the tongue becomes pointed, the body cool
and clammy, the pulse feeble and irregular, and the patient dies from
asthenia.
698
A SYSTEM OF MEDICINE.
Diagnosis.—Acute enteritis is chiefly distinguished from simple
diarrhoea, dysentery, typhoid fever, peritonitis, gastritis, typhlitis, and
colic. Diagnosis from simple diarrhoea is often difficult, though not
really essential. Many cases of simple diarrhoea result from a slight
enteritis, and it is often impossible to separate them. In dysentery,
the presence of the characteristic tenesmus and bloody mucous stools,
together with an absence of the colic-pains about the umbilicus, are
sufficient to establish a correct diagnosis. Typhoid fever may be ex-
cluded by the absence of its characteristic features of slow and regular
development, associated with adynamic conditions, while the severe
umbilical pains of enteritis are not a feature of typhoid fever. Ente-
ritis simulates peritonitis more than any other affection, but in the
latter the pains are more intense, and the tenderness and tympanitis
greater. The abdominal muscles are rigid in peritonitis, which is not
the case in enteritis, and there is present more profound constitutional
disturbance. In cases of severe localized enteritis, involving the whole
bowel, it is not easy to make a diagnosis, in fact in such cases the peri-
toneum is usually involved along with the other intestinal coats, and
this is more evident if the pain and tenderness are marked, super-
ficial, and extensive.
Gastritis may be suspected when nausea and vomiting are the prom-
inent features, and when the tongue presents the characteristic red,
irritated appearance of gastritis, especially at the tip and margins.
Sometimes both diseases exist at the same time, especially as the
result of poisoning by irritant substances. In typhlitis the symp-
toms are more localized in the right iliac fossa. Colic is recognized.
by the characteristic pain, the absence of fever and other constitu-
tional disturbances, and the presence of constipation rather than diar-
rhoea.
Prognosis.-Ordinary catarrhal enteritis seldom results fatally, ex-
cept when occurring in connection with other diseases or in persons.
of a feeble constitution. Copious inflammation is more apt to result
unfavorably, though even here a fatal result is rather the exception.
Persons once having had croupous enteritis are liable to a renewal of
the attack after a few weeks or months, or even years.
Follicular enteritis often proves fatal, but under careful homoeo-
pathic treatment we are usually able to offer a favorable prognosis.
Inflammation involving the entire thickness of the bowel, whether un-
complicated, as here considered, or connected with strangulated hernia,
intussusception, or some other grave lesion, is a rapidly fatal disease,
usually producing a fatal termination inside of a week, and sometimes
within one or two days.
Treatment.-Inflammation of the serous and muscular coats of
the intestines, and that form of inflammation which involves the en-
tire structure of the bowel, so rarely occur primarily that their pro-
DISEASES OF THE ORGANS OF DIGESTION.
699
phylaxis is best considered in connection with those diseases with
which they are usually associated.
Catarrhal and croupous inflammation occurring in the adult may
only be avoided by attention to those hygienic measures which serve
to impart tone and vigor to the general system, and which regulate
the functions of digestion. Wholesome diet, exercise, bathing, and
regularity in habit, if persevered in, will do much to overcome any ex-
isting predisposition to these affections.
It is in the enteritis of childhood, especially in that form described
as enteritis folliculosa or entero-colitis, that preventive measures are
most important. These consist chiefly in attention to diet, dress, and
habitation. The child should be kept at the breast, unless it is evi-
dent that, from any cause, the mother's milk has become unhealthy,
when a wet nurse should be procured, or, failing in this, the artificial
diet should be made to correspond as nearly with the human milk as
is possible. Cream diluted with two parts of water, and sweetened
with sugar of milk, is an excellent and easily obtained substitute.
Fresh milk, diluted with barley water, or with a solution of gelatine,
is used by many. It is of the utmost importance that the milk be
pure and sweet, and that the bottle from which it is fed, or the vessels
which contain it, are kept scrupulously clean and sweet. Sometimes
milk in any form will aggravate the disease, when recourse may be had
to boiled flour, Graham meal, or oatmeal, largely diluted with water, or,
sometimes, Horlick's or other prepared foods may answer a still better
purpose. In my own practice I have had the best results from the
use of flour browned in the oven, and prepared in water previously
sweetened with sugar of milk. In case the child has been recently
weaned, it is best to return it at once to the breast.
The dress should be such as to protect from atmospheric changes.
Except in the hottest weather, flannel should be worn next to the
skin. In summer this may consist of a light silk flannel, or of soft
cotton and wool flannel. In removing this garment during the hot
weather, great care should be exercised, and it should be returned on
the first indication of a cool or damp change.
Sometimes the disease may arise from atmospheric influences other
than those from which dress may afford protection. The noxious
gases which arise from animal or vegetable decomposition in the
summer months often, especially in cities, give rise to intestinal in-
flammation, and it is desirable, when a possible thing, to remove to
a more salubrious locality, any high open country in the immediate
vicinity answering the purpose, probably, fully as well as a seaside or
mountain resort requiring a long and tedious journey to reach it.
Those not able to make such a temporary change of residence should
keep their child much in the open air, taking it daily to some public
common or park, and permitting it to ride and play during most of
700
A SYSTEM OF MEDICINE.
the day, not, however, forgetting the necessity of protecting it from the
sun during the heat of the day, and allowing it to have its accustomed
midday sleep.
The more extended remarks on the subject of prophylaxis and hy-
giene in the article on cholera infantum apply equally well here, and
to them the reader is referred.
In older children a judicious diet of milk, eggs, meat, and vegetables
is desirable, avoiding all starch, fatty and saccharine articles of food.
Aconite is frequently the remedy in the first stage of any intestinal inflamma-
tion, especially when resulting from cold. There is a rapid pulse, considerable heat,
intense thirst, and great restlessness. There may be a swollen, hot, and tender abdo-
men, and stools resembling chopped herbs.
Æthusa is especially useful in children when there is a great intolerance of milk,
which is forcibly ejected as soon as swallowed; vomiting of curdled milk and cheesy
matter; dozing after the vomiting spells; abdomen swollen and tense; stools bright
yellow, or greenish, watery; pulse small but very rapid; linea nasalis; convulsions
with clenching of the thumbs, turning downwards of the eyes, and foam at the mouth.
Apis mel. is indicated when, in children, the inflammation has been protracted
until anæmia and nervous exhaustion have reached such a degree as to terminate in
hydrocephaloid. The patient may have greenish-yellow stools mixed with mucus, or
they may be thin and watery; abdomen sore and distended; urine scanty; no appe-
tite or thirst; sopor, interrupted by piercing shrieks; squinting, grinding teeth, boring
head into the pillow.
Arsenicum is useful in severe attacks, or in the last stages of any form of ente-
ritis. Abdomen distended and painful; stools acrid, black, dark colored, green, bloody,
or watery; painless, offensive, involuntary; burning pains in stomach and abdomen;
pulse quick, weak, and irregular; great thirst, but drinks little at a time; great rest-
lessness and anxiety; weakness and prostration; face hippocratic, pale, covered with
cold sweat. All symptoms worse after midnight.
Belladonna.-Sudden attacks, or sudden aggravation of an existing attack.
Abdomen distended and very sensitive to touch; tenderness aggravated by the
slightest jar or motion; stools of green mucus, or containing lumps like chalk; tem-
perature much increased, face red, pulse accelerated, delirium; startings and twitch-
ings during sleep.
Bryonia.-Aggravated by the return of every spell of hot weather, or when hot
weather seems to develop the attack. Abdomen distended, sensitive, and sore; offen-
sive, bilious, acrid stools, or constipation with stools large, hard, and dry as if burnt;
tongue thickly coated white; great thirst for large quantities of water; lips dry and
parched; pains worse on motion.
Calcarea ostrearum.-Especially useful in chronic varieties; fair plump
children; during dentition, open fontanelles; in scrofulous persons of a leuco-phlegmatic
temperament. Abdomen hard and very much distended; stools undigested, white,
clay-colored, sour; patient emaciated, flabby, skin dry and shrivelled; head sweats
when sleeping.
Calcarea phos.—Chronic varieties, during dentition or in old people. De-
layed closure or reopening of fontanelles. Offensive stools; aching soreness and pain
around the navel, relieved by passing flatus; pain in abdomen, heartburn and other
gastric symptoms after eating.
Carbo veg.-Last stages. Especially old people and children; venous system
predominant. Vital forces nearly exhausted, cold surface, especially below knees to
feet; lies as if dead; breath cool; pulse intermittent, thready; cold sweat on limbs;
voice hoarse or lost
Cinchona.-Abdomen distended and tympanitic; flatulent, painless, debilitat-
ing diarrhoea, watery or containing portions of ingesta; aggravation from eating, es-
pecially fruit; attack may have originate 1 from eating fruit. Malarious origin; worse
every other day; great debility and prostration.
Helleborus.-Abdomen distended; gurgling as if the bowels were full of
water; stool consisting solely of clear, tenacious, colorless mucus; weakness; features
DISEASES OF THE ORGANS OF DIGESTION.
701
sunken, face cold, pale, covered with clammy sweat; pulse thready; head hot, heavy;
boring head in the pillows; hydrocephaloid.
Mercurius.-Abdomen hard, distended, and painful; bruised feeling in in-
testines; violent colic, with cutting and stinging pains, as if caused by knives, worse
from even touching anything cold; stools slimy and bloody, or dark green, with much
straining; worse at night; sweat without relief.
Mercurius corr.-In advanced stages of any variety, with phagedenic ten-
dency. Abdomen distended and very painful to the least touch; violent burning, es-
pecially in rectum and anus; stools frequent, nothing but mucus tinged with blood;
corrosive ichor oozes from the anus and excoriates the parts; very distressing tenesmus
and burning; lies on back with knees flexed; pulse small, intermittent, irregular;
surface cold and covered with a clammy perspiration.
Nux vomica.-In children where some marked error in diet has caused indi-
gestion; also in older persons when the attack is the result of long-continued errors in
diet, sedentary life, and constipation; bruised, sore pain in intestines; frequent and
ineffectual desire for stool; vomiting; bad taste in the mouth; tongue coated thick
white. After the use of cathartics and patent medicines.
Phosphorus.-Abdomen tympanitic, very painful to touch; painless, watery
discharges, especially in the morning after getting up; in children the watery stools
contain little lumps of undigested casein, that look like tallow; in debilitated, con-
sumptive patients; in lying-in women; great emaciation, weakness and prostra-
tion.
Podophyllum.-One of our best remedies in entero-colitis. Stools change-
able in character, worse in the morning; profuse, gushing, painless, fetid; green,
sour; yellow; undigested; slimy; clay-colored or like chalk; vomiting of green frothy
mucus or of food; during dentition; moaning during sleep, with half-closed eyes, and
rolling the head from side to side (incipient hydrocephaloid).
Sulphur.-In scrofulous or delicate people or children. When there are re-
peated relapses, or when the case seems to linger, and remedies do not act. Abdomen
distended, tense, and sensitive to touch; stools watery, green, or yellowish, often
streaked with blood; very excoriating; worse in the morning; prolapsus ani; itch-
ing, burning, sweating in the anus; milk disagrees and causes much distress.
Veratrum alb.—Attacks coming on suddenly during the hot season, with
choleraic symptoms; severe cases in the last stage; violent forcible vomiting; worse
from the least motion, or after drinking, with cold sweat, especially on the forehead.
Pulse almost imperceptible. Prostration with cold sweat and cold breath. Stools
copious, watery, greenish, mixed with flakes. Excessive thirst for cold water.
Consult also: Antimonium crud., Argentum nit., Baptisia, Benzoic
acid, Bismuthum, Chamomilla, Camphora, Colocynthis, Croton tig.,
Dulcamara, Ferrum, Graphites, Hepar, Ipecacuanha, Iris, Kreasotum,
Magnesium carb., Rheum, Enothera biennis, Phosphoric acid.
DUODENITIS.
BY A, C. COWPERTHWAITE, M.D., PH,D,
Definition.-Inflammation of the mucous membrane of the duo-
denum; duodenal catarrh.
Etiology. It is usually considered that an inflammation of the
duodenum most often arises from the extension of a gastric inflamma-
tion induced by indiscretion in eating, the indigestible food passing
from the stomach into the duodenum in an unchanged condition.
On the other hand, duodenitis may arise from an extension upward
of an inflammation of the lower portion of the small intestine. It
may also occur independent of either gastritis or enteritis, and under
702
A SYSTEM OF MEDICINE.
such circumstances usually results from climatic changes, malarial
influences, or from some severe and prolonged external irritation
which produces hyperæmia, and, finally, inflammation, in a similar
and equally mysterious manner, as a severe burn on the skin produces
a sloughing ulcer at the upper part of the duodenum within a few
days after the burn occurs.
Pathology. The duodenal mucous membrane becomes red and
greatly swollen and oedematous, especially about the orifice of the
common bile-duct, which empties into that part of the canal and
whose orifice is thus occluded, this giving rise, as is usually supposed,
to the catarrhal jaundice which is so characteristic of this affection,
though Dr. Flint considers it more probable that this jaundice results
from an extension of the inflammation into the duct.
Symptomatology.-When duodenitis occurs as an extension of a
gastric inflammation, it is preceded for days or, possibly, weeks, by
symptoms of gastric catarrh, pain and disorder of digestion, nausea
and vomiting. Symptoms somewhat similar often accompany duo-
denal inflammation, even though there be no gastritis. Obscure pain.
felt in the right hypochondriac and umbilical regions, uneasiness and
distress occurring about three hours after food has been taken, and
tenderness below the epigastrium over the site of the duodenum, are
characteristic features of the disease. Occasional attacks of hepatalgia
may occur, the paroxysms of pain being quite severe, but with no
increase of the local tenderness. About the third day, or from that
to the seventh, the conjunctiva begins to turn yellow, the tongue is
coated, the breath fetid, there is considerable headache, more or less
stupor, and great depression of spirits. The yellowness increases, and
continues to extend until the icterus becomes universal, when we have
presented, to a greater or less extent, the symptoms usually accom-
panying jaundice. While this icteric condition is considered charac-
teristic of duodenal catarrh, and a diagnostic feature, yet it may occa-
sionally be absent, and in such cases the true nature of the disease is
often not accurately determined, sometimes not even suspected. After
two or three weeks the local symptoms subside, the icterus gradually
disappears, and the patient is well, save the great debility which re-
mains and which is usually quite out of proportion to the severity of
the disease. Sometimes the acute merges into a chronic form, and
becomes associated with various forms of hepatic derangement, which
are indefinite in their course and termination. Occasionally a case is
less severe from the beginning, but more protracted in its course, often
lasting several months. Such is the chronic variety, which presents
no features distinctive from the acute.
Diagnosis.-Duodenitis need not be confounded with gastritis if
we bear in mind the local pain and soreness, the fact that food does
not cause distress until three hours after eating, and the icterus occur-
DISEASES OF THE ORGANS OF DIGESTION.
703
ring within a few days. In hepatic colic the pains come on suddenly
and with extreme severity, producing a cold surface, weak pulse, and
incessant vomiting, and then, after a time, cease as suddenly as they
came, leaving the patient entirely relieved.
The presence of gall-stone also confirms the diagnosis. In hepa-
talgia there is no local soreness, and the neuralgic pain ceases after a
time, leaving no constitutional symptoms.
Prognosis. The prognosis in uncomplicated duodenitis is always
favorable.
Treatment. In the treatment of duodenitis the diet is of great
importance. An exclusive milk diet is highly recommended and well
worthy of trial. Dr. Bartholow says that "the diet should be re-
stricted to those substances convertible into peptones in the stomach,
as milk, whey, buttermilk, eggs, animal broths, and all saccharine,
starchy, and fatty constituents should be avoided. Fresh meats, game,
poultry, and fish, without butter or fat, are admissible if the stomach is
equal to their digestion. The most rapid progress can be made by ad-
hering to an exclusive diet of milk, and, as there is complete anorexia,
this is usually not difficult." The patient should remain quiet in bed.
Hot poultices or fomentations, or the ice-bag, may be applied externally.
Podophyllum.-I have found this the most important remedy. Fulness, with
pain and soreness in the right hypochondria; diarrhea, stools constantly changing in
appearance, green, yellow, clay-colored, like chalk, or watery; worse in the morning;
affection of the biliary ducts and tendency to jaundice.
Mercurius is the remedy next in importance. Region of duodenum swollen
and sensitive, with cutting pains as from knives; tongue swollen and thickly coated
white; stools green, or of green mucus; icterus. All symptoms aggravated by cold.
Attacks caused by exposure to cold.
Chelidonium.-Abdomen hard and distended; hepatic region sensitive to
touch; griping, cutting, or stitching pains; stools thin, bright yellow; urine dark
yellow; tongue thickly coated yellow; bitter taste; complete icterus; pain in or be-
neath the right shoulder-blade.
Arsenicum.-Chronic form, especially when occurring as an extension of gas-
tritis or enteritis. Also in later stages of severe acute attacks. Intense burning pains
about the region of the duodenum; obstinate vomiting; stools black, green, dark-
colored, watery, offensive; great restlessness and prostration.
Kali bichr. is supposed to have a specific action on the duodenum. Abdomen
distended; stitches extending through to the spinal column; vomiting; stools of brown,
frothy water; tongue coated thick, whitish yellow.
Consult also: Aconite, Belladonna, Cinchona, Nux vomica, Phosphorus,
Sulphur.
CONSTIPATION.
BY A. C. COWPERTHWAITE, M.D., PH.D.
Definition. By constipation we understand a retarded and insuf-
ficient evacuation from the bowels of hard dry fæces.
Etiology. Constipation may be caused by a mechanical obstruc-
tion in some part of the intestinal tract, directly interfering with the
704
A SYSTEM OF MEDICINE.
passage of the fæces. This is sometimes termed obstipation, and will
be separately considered. Constipation may be due to a great variety
of causes, chief of which are errors in diet and the habitual neglect
of the act of defecation, from carelessness, want of time, or undue
modesty. If the former, the use of a large amount of indigestible
food, which forms dry fæces, and the excessive use of coffee, are im-
portant factors. Constipation will also result from the habitual use
of opium and from lead poisoning. Sedentary habits favor constipa-
tion, especially when accompanied by an irregular and injudicious.
diet. It may be brought about by any of the causes which produce
weakness of the muscular fibres of the intestines-anæmia, chlorosis,
and other enfeebling diseases, chronic enteric catarrh, the habitual use
of purgatives, or, more often, dilatation of the bowels from habitual
neglect, thus resulting in deficient peristaltic action. Constipation.
may also result from an abnormal loss of fluids by perspiration, diu-
resis, or excessive lactation, rendering the fæces preternaturally dry;
from an inactive state of the rectum; from ovarian or uterine derange-
ments, which partially account for the special predisposition to con-
stipation in the female sex; from hepatic derangements; from various.
chronic affections, especially those connected with the nervous system.
Constipation also frequently accompanies acute febrile diseases, such
as typhoid or scarlet fever, but under such circumstances should
always be considered as a favorable symptom, and not be interfered
with by the use of purgative medicine.
Pathology.-Constipation, in the sense in which it is usually consid
ered, may not always constitute an abnormal condition. Ordinarily, a
person should have one free evacuation each day to be in good health,
yet this is not an invariable rule, as many persons who enjoy good
health have two or three evacuations daily, or, on the other hand, only
defecate once in every few days. In fact, instances are not as rare as
may be supposed of persons who habitually go from four to six weeks
without an evacuation. A case of this kind has been under my ob-
servation more or less for the last twelve years. A single man, of spare
habit, now about fifty years of age, a stone-mason by occupation, whose
habits of life have, with the exception of the use of tobacco, been very
simple and regular, and whose health has always been unusually good
since his youth, has not had evacuations from the bowels oftener than
once in six weeks, and when occurring oftener than this, they have
caused him more or less discomfort. This is quite an unusual case from
the fact that the prolonged retention of feces appears to be entirely
habitual, and does not appear to affect his health. It is quite apparent
that what constitutes an abnormal retention of fæces in one person,
may not be so in another. The most important pathological changes
which characterize constipation are those which naturally result from
the irritating presence of the retained hard and dry fæces, redness and
DISEASES OF THE ORGANS OF DIGESTION.
705
congestion of the mucous membrane being the first, and sometimes
the only, symptom produced. This congestion may, however, go on
to inflammation, ulceration, and even perforation of the bowel, which
is first greatly dilated and hypertrophied. Such instances are perhaps
rare, the most common result being a retardation of blood in the
hæmorrhoidal veins, giving rise to hæmorrhoidal tumors. Dr. Bristowe
records two fatal cases which give an excellent illustration of the con-
ditions resulting from long-continued constipation. The first case was
that of a little girl, eight years old, whom he saw casually only during
life, and of whose history he obtained, after her death, some not very
perfect details. She had long suffered from tendency to constipation,
and it was stated that she had occasionally gone as long as three weeks
without an evacuation. At the time of her admission into the hos-
pital, there had been no relief of the bowels for some weeks. She was
then pale and thin, had a large, tense belly, without pain or tenderness,
a clean tongue, and poor appetite. She had a "strumous " look, and
was supposed to be suffering from abdominal tubercle. She became
gradually more and more emaciated and anxious-looking, while the
belly grew larger and more tense. She never had any distinct abdom-
inal tenderness, but suffered at times from colicky pains, and often
(especially toward the close of life) complained that she was so full
she felt as though she would burst. During the last week, or two, the
tongue became somewhat foul, and she had frequent vomiting, but
never of stercoraceous matter. She passed only little urine, which
was high-colored. She sank gradually from exhaustion, and died
exactly three weeks after admission. At the post-mortem examina-
tion, the form of the distended intestine was distinctly impressed on
the tense and thin abdominal walls, and on opening the abdomen the
enormously enlarged colon was first alone visible. The distension.
began at the cæcum, and extended to within two inches of the anus,
where it ceased abruptly. In the greater part of its extent the bowel
measured from nine to ten and a half inches in circumference, the
greater amount of distension being manifested in the sigmoid flexure.
The muscular walls were hypertrophied from the ascending colon to
the lower end of the sigmoid flexure; and, in the latter situation, where
the hypertrophy was greatest, they measured one-eighth inch in thick-
The mucous membrane seemed healthy in the greater part of
its extent, but it presented some congestion here and there, and at
distant intervals large patches in which there were groups of small
circular shallow ulcers. The bowel contained no flatus, but was com-
pletely full of thick, semi-solid, olive-green colored fæces. These were
more solid in the rectum than elsewhere, and immediately above the
anus formed an indurated conical lump. The small intestines were
* Reynolds, vol. iii., page 168.
ness.
VOL. I.-45
706
A SYSTEM OF MEDICINE.
also considerably distended, though much less so than the larger
bowel, and were filled throughout with semi-fluid olive-green colored
contents. The stomach was small and healthy, and empty. There
was no other disease. There can be no doubt that death was caused
from simple constipation neglected, that the indurated fæcal lumps
above the anal orifice had formed a plug which the bowel was unable
to expel, and which the accumulation of more and more fæces above
and around it had served only to fix more firmly. That the bowel
had striven to expel its contents was shown by the hypertrophied
condition of its muscular coat. The second case, above mentioned,
was that of a young man aged twenty-four, who also had been the
subject of habitual constipation; and who, on one occasion, after the
persistence of constipation for an unusually long period, was attacked
with diarrhoea which lasted about six weeks and was followed by
sudden peritonitis, of which he died. There was found after death
inflammation of the peritoneum, due to a perforation in the trans-
verse colon, great dilatation and thickening, yet almost complete emp-
tiness, of the whole length of the large intestine, and just the same
kind of ulceration of the mucous membrane in patches as that de-
scribed above.
It was in one of these patches that perforation had taken place.
Here, as in the former case, it is obvious that long-continued consti-
pation had caused permanent thickening and dilatation of the large
intestine, and ulceration of the mucous surface; but here, addition-
ally, after the relief of the constipation, the ulceration had provoked
and maintained a condition of diarrhoea, and ultimately caused per-
foration.
Symptoms. In addition to the symptoms of retained fæces, con-
stipation may give rise to a long train of subjective phenomena so
varied in character that they can hardly be compassed in this article.
Local uneasiness, pressure or weight in the perinæum,. a sense of ab-
dominal distension, flatulence and colicky pains, together with dul-
ness of the intellect, headache, languor, palpitation, furred tongue,
bad breath, loss of appetite, with general dyspeptic symptoms and
the usual phenomena attendant upon a too prolonged retention of the
fæces, while severe straining at stool may cause cerebral hemorrhage
and hernial protrusions. Sometimes the difficult defecation is accom-
panied by much pain, and leaves behind more or less aching, burning,
and soreness in the anus, from the passage of the hard mass of fæces,
which not unfrequently so irritates the mucous membrane as to pro-
duce dysenteric symptoms. The general effects upon the system are
sometimes well marked. The nervous system becomes depressed and
irritable, and anæmia and emaciation may result from the disturbance
of the nutrition.
Diagnosis. The diagnosis of constipation rarely presents any
DISEASES OF THE ORGANS OF DIGESTION.
707
difficulty. If the accumulation of retained fæces is very large, it may
simulate an abdominal tumor, or by its irregular character may lead
to suspicion of the existence of a cancerous mass. It should be borne
in mind, however, that the enlargement, if due to fæcal accumulation,
will correspond in form and position to the shape of the cæcum or
to some part of the colon, and will usually have a slight doughy feel,
yielding to pressure, and retaining its altered shape after the pressure
is removed. In such instances resort should be had to the thorough
use of enemas before a positive opinion is given.
Prognosis. When constipation is not due to incurable diseases
or to mechanical obstructions which cannot be removed, or has not
progressed to a point where ulceration is extensive and perforation.
threatening, a favorable prognosis may always be given. Much of the
result of treatment, however, will depend upon success in controlling
the habits of the patient, and upon enforcing proper dietetic regula-
tions, without which, in most cases, little can be accomplished.
Treatment. It is comparatively seldom that constipation occurs
primarily, except from errors in diet and irregular habits, such as have
been enumerated. In such cases it is only necessary to enforce such
rules of diet and living as are best adapted to the individual. Prompt
obedience to the calls of nature and a judicious system of diet are
usually sufficient to prevent the occurrence of constipation. Too
much importance cannot be attached to the habit of regularly and
systematically attending to the calls of nature. Daily, at some con-
venient hour, perhaps soon after a meal, at which time there is a
natural tendency to peristaltic movements, the patient should retire
to the closet and at least solicit an evacuation, though not persist
in fruitless efforts by violent straining. Plenty of time should be
allowed, and no excuse be permitted to interfere with the performance
of this important duty. At first, there may seem to be no beneficial
result, but after a time, if the habit is persevered in, nature will re-
spond. It is probable that without the strict observance of this rule
no case of habitual constipation can be permanently cured. The
necessities of nature, from press of business or from notions of false
delicacy, are too often neglected, especially in the case of girls attend-
ing school, or in those who are employed as saleswomen, clerks, and
seamstresses in large establishments where proper and convenient
resorts are not provided.*
In the matter of diet the use of oatmeal and cracked wheat, or bread
* A proposition has just been made by a physician in New York to the effect that
a commissioner be appointed by the city, whose business it shall be to visit all places
of business where help is employed, for the purpose of examining and regulating
water-closet privileges, with legal authority to require every person employing help
to provide and properly maintain such conveniences. No better move for promoting
the public health could probably be inaugurated.
708
A SYSTEM OF MEDICINE.
made from "graham" or bran flour, together with laxative fruits, such
as apples, figs and prunes, are the most important. Often, the adoption
of such a diet, with the free use of such vegetables as leave after diges-
tion a bulky residuum-cabbage, lettuce, etc., is all that is required to
overcome habitual constipation. A ripe apple or a glass of water taken
in the morning before breakfast is very beneficial. Drinking a cup of
hot water several times each day, often cures after other measures have
failed.
It is often necessary to resort to enemas, which may be used at the
same hour daily, in conjunction with the appropriate homœopathic
remedy, until the action of the latter renders the enema unnecessary.
It is no doubt true that the long-continued use of enemas tends to
produce paresis of the rectum, or, at least, the rectum grows so ac-
customed to the fæcal distension that after a time it fails to excite the
peristaltic action, and the enema becomes of comparatively little bene-
fit. Physical exercise, such as walking, or riding horse-back, not
carried to excess, is of much benefit, and friction over the bowels,
made with a flesh-brush or crash towel, should be liberally practiced.
Therapeutics.-Nux vomica is especially indicated in persons who lead seden-
tary lives; who are irritable and hypochondriacal; who freely use coffee or liquors and
purgative medicines, and are subject to hæmorrhoids; the fæces are large and hard-
frequent and ineffectual desire for stools; headache, especially in the morning; un-
refreshing sleep; dyspepsia. The constipation of Nux vomica is due to an irregular
or spasmodic action of the intestine, and not to inactivity.
Bryonia.-Stools large, hard and dry, as if burnt; passed with great difficulty;
bitter taste in the mouth; tongue thickly coated white; pressure as from a stone after
eating; disposition to headache, with irritability and anger of the patient.
Opium.—Inactivity of the bowels; stools composed of hard, round black balls;
no inconvenience from the accumulation on account of the even sensibility in the
parts; incarcerated hernia; lead-poisoning.
Alumina.-Inactivity of the rectum; even the expulsion of soft stool requires
great straining; no desire for stool and no ability to pass it until there is a large ac-
cumulation; stools hard and knotty, like sheep-dung, with cutting in the anus, followed
by blood; constipation in nursing children; from lead-poisoning.
Lycopodium.-Ineffectual urging, owing to contraction of the rectum, which
protrudes during stool; small stool, with sensation as if much remained unpassed; large
accumulation of gas in the bowels, with much rumbling; torpor of the bowels; in nurs-
ing children and in elderly people.
Plumbum.-Stools small, hard, in lumps or balls, like sheep-dung; colic; re-
tracted abdomen; painful contraction of the anus; when Opium is indicated and has
failed.
Sulphur.-Stools scanty, difficult and insufficient; hard as if burnt, ineffectual
urging; itching and pressure in rectum during a stool; burning in anus after stool;
habitual constipation, especially in persons subject to hæmorrhoids or in scrofulous
persons.
Consult also Esculus hipp., Ammon. muriat., Calcarea ost., Graphites,
Hydrastis, Magnesia mur., Nitric acid, Phosphorus, Platina, Silicea, Zincum.
DISEASES OF THE ORGANS OF DIGESTION.
709
INTESTINAL HÆMORRHAGE.
BY A. C. COWPERTHWAITE, M.D., PH.D.
Synonym.-Melæna.
Etiology. Intestinal hæmorrhage often arises from some morbid
condition which produces obstruction of the portal circulation, as in
obstructive diseases of the liver, especially cirrhosis, and in chronic
diseases of the heart and lungs. It may also arise from diseases and
injuries which involve the walls of the vessels, as in ulceration; such
are the hæmorrhages which occur during typhoid fever, dysentery and
intestinal tuberculosis, or which result from mechanical or chemical
injuries, and consequent degeneration, or after the use of violent purga-
tives, irritant poisons, the passage of hardened fæces and rough calculi.
Hæmorrhage also occurs from the intestines, as from other mucous sur-
faces, as a result of certain morbid blood states, as in scorbutic affec-
tions, purpura, etc. Also in yellow-fever and malignant jaundice,
though in these it may sometimes arise secondarily from the ulcera-
tion and degeneration of the intestinal mucous lining which may take
place in these affections. It may occur as a vicarious discharge, taking
the place of normal menstruation, just as vicarious hæmorrhages occur
from other mucous surfaces.
It also accompanies hæmorrhoids, either from rupture of the greatly
distended and thinned walls of the hæmorrhoidal veins or inflamma-
tion and erosion of the tumors. It occurs in intussusception of the
bowels, from the venous congestion which results as a consequence of
the mesentery being dragged into the sheath along with the invaginated
part, and the vessels being thereby compressed; hæmorrhoids and in-
tussusception being elsewhere considered, the hæmorrhage so occa-
sioned will not be considered under this head.
The bursting of an aneurism, emptying its contents into the intestine,
or the passage of blood from the stomach into the bowels, after hæma-
temesis, also accounts for the occurrence of hæmorrhage from the bowels.
Bamberger gives the following ætiological scale which shows the order
of frequency of the occurrence of intestinal hemorrhage: dysentery;
typhus; cancer (of the large intestine); mechanical hæmorrhage; poi-
soning; foreign bodies; tuberculous, follicular, catarrhal ulcers and in-
flammations of the mucous membrane; the round duodenal ulcer;
aneurisms; and, finally, vicarious hæmorrhages.
Leube holds that gastric hemorrhages occur more frequently in
women, but that the reverse is the case in regard to hæmorrhages from
the intestines.
Pathology. In persons who have died from profuse intestinal
hæmorrhage the body presents the signs of general loss of blood. On
* Ziemssen, vol. vii., page 448,
710
A SYSTEM OF MEDICINE.
opening the abdominal cavity, the mesentery, in some instances, ap-
pears engorged with blood, especially in cases of congestive hæmor-
rhage, and the intestine, on section, is found to be intensely hyperamic;
at other times, however, the mucous membrane is very pale, in con-
sequence of the copious hæmorrhage which has occurred during life.
In still other cases the mucous membrane has a dark speckled appear-
ance, which is produced partly by ecchymoses and partly by effused
blood, which may be pressed out of the orifices of the follicles. The
cavity of the intestines is filled with dark, blackish-brown, tarry clots
of blood, although at times the blood is red and of a more fluid con-
sistence. After removing these clots, it is generally possible to dis-
cover the cause of the hæmorrhage, either in the form of an eroded
vessel lying in the base of an ulcer, an invagination, an embolism of
the superior mesenteric artery, aneurism, cancer, etc., or in the form of
an intense enteritis, an amyloid degeneration of the intestine, or dif-
fused congestion in the ramifications of the portal vein. In cases of
capillary hæmorrhage the explanation of the bleeding will not be
found until inquiry is made into the pathologico-anatomical condition
of the liver, heart, etc. (Leube.)
Symptomatology. The symptoms produced by intestinal hæmor-
rhage vary according to the nature of the diseased condition which.
causes it. If considerable, we obtain the usual symptoms of intestinal
bleeding,-deadly pale face, glassy eyes, cold skin, weak pulse, ringing
in the ears, giddiness, glimmering before the eyes, and faintness. Some-
times consciousness is entirely lost, and the patient dies at once, with-
out any escape of blood externally; usually, however, there is ex-
perienced a sudden and irresistible desire to evacuate the bowels, and
there is had one or more discharges of fluid and clotted blood, or of a
blackish, semi-fluid, tarry mixture. If the quantity is small and comes.
slowly from the upper part of the small intestines, it is usually more.
or less dark, being often quite black, and presenting a tarry, sooty
aspect; occasionally it resembles coffee grounds. If originating from
the same source, being at the same time copious and speedily expelled,
it may be little altered, though it is usually of a very dark color. This
change in the character of the discharge is due to the action of the acid.
contents of the intestines, transforming the hæmoglobin of the blood
into hæmatin. When coming from the large intestines, especially near
the anus, the blood is generally quite bright and unchanged. If the
bleeding originates in the rectum, the discharges may take place be-
fore, with, or after, the passage of fæces, which may be covered with
blood, but are not mixed with it. Should the blood continue to escape
in only small quantities and slowly, it causes gradually increasing
weakness and anæmia; but if the discharge is copious, and the attacks
are repeated in quick succession, we get the evidences of collapse be-
fore mentioned. If the hæmorrhage is arrested, normal stools appear
DISEASES OF THE ORGANS OF DIGESTION.
711
in due time, and the patient slowly regains his health and strength.
Relapses are quite common, and depend not only upon the habits and
conduct of the patient during convalescence, but also, and largely, upon
the etiological conditions present.
Diagnosis. It is of first importance to determine whether, or not,
the discharge consists of blood, as the black, tar-like appearance of
the stool may arise from the use of iron, or more often from the ad-
mixture of bile. This may easily be settled by a microscopic or spec-
troscopic examination for hæmatin; but a simpler and much more.
available plan is to throw the discharged mass into water; if contain-
ing blood, it will color the water red; if it only contains bile, the water
is colored green or yellowish.
It must next be determined from what locality the hæmorrhage
arises. The symptoms already given usually are sufficient to approxi-
mately locate the origin of the hæmorrhage. So also, if the character
of the disease which causes the hæmorrhage is once ascertained, we can
readily locate the point of discharge. For instance, if we discover that
the bleeding is hæmorrhoidal, or occurs in typhoid fever, in dysentery,
etc., we can at once, and positively, locate the source of the bleeding.
Prognosis. Intestinal hæmorrhage, when not resulting from hæm-
orrhoids, may also be considered a grave symptom the full import of
which can only be understood by a knowledge of the morbid state
which is producing it. Mild hæmorrhages may often be not only
harmless but apparently beneficial; they are at times followed by the
relief of distressing symptoms, and often, in grave acute diseases, mark
the critical period where convalescence begins. When, however, the
hæmorrhage becomes profuse, whatever be the cause, it may well ex-
cite serious apprehensions. The patient may succumb at once, or the
hæmorrhage, even if checked, may recur.
The prognosis properly depends upon the amount of blood lost and
upon the nature of the morbid condition which forms the primary ætio-
logical factor in the case.
Treatment. Intestinal hemorrhage then is but a symptom of the
disease with which it is associated. While the treatment must be
chiefly medicinal, the same general principles and methods are, to a
considerable extent, required in its management upon which depend-
ence is placed in managing other forms of hæmorrhage. Persons sub-
ject to bleeding from the bowels should scrupulously avoid violent
exercise at all times, and during the attack, and for some time after,
absolute quiet is indispensable. Sometimes, ice-bags applied to the
abdomen are of great service. The continuous injection of hot water
is one of the safest and most reliable auxiliary measures.
Drinking of alum whey has been highly recommended.
It is very seldom that the proper remedies fail to check the hæmor-
rhage, and the auxiliary measures so necessary in the ordinary treat-
712
A SYSTEM OF MEDICINE.
ment of this symptom, are seldom required by the homœopathic physi-
cian.
Therapeutics.-Ipecacuanha.- Hæmorrhage of profuse, bright red blood;
heavy, oppressed breathing; nausea and inclination to vomit.
Hamamelis.-Passive hæmorrhage of dark venous blood, sometimes in large
quantities.
Erigeron.-Profuse flow of bright red blood; every movement increases the flow.
Cinchona.-Passive hæmorrhage after exhausting diseases; great debility; ab-
domen tympanitic; coldness and blueness of the skin; suitable to persons who have
lost much blood, even in severe cases; heaviness of head, ringing in ears, vertigo,
vanishing of senses, sopor, fainting fits, cold extremities, face pale and sunken.
Arsenicum.-Tedious, long-continued passive hæmorrhages, resulting from con-
stitutional diseases, such as carcinoma, typhoid fever, purpura, etc.; great debility, and
lancinating burning pains; great mental restlessness and anxiety; face pale, sunken,
deathly, or having a yellow, cachectic look.
Carbo veg.-Passive venous hæmorrhage, after protracted and exhausting dis-
eases; vital forces nearly exhausted; cold surface, especially below knees to feet; lies
as if dead; breath cold; pulse intermittent, thready; cold sweat on limbs; especially
in old people or children.
Sulphuric acid.-Hæmorrhage of black blood; extreme weakness and ex-
haustion; weak feeling in abdomen; profuse perspiration; especially in old people.
Consult Aconite, Arnica, Crocus, Millefolium, Nitric acid, Phosphorus,
Sulphur, Terebinthina.
TYPHLITIS.
BY A. C. COWPERTHWAITE, M.D., PH.D.
Synonyms. Typhlitis stercoralis, Typhlo-enteritis, Cæcitis.
Definition. This affection consists in an inflammation of the
walls of the cæcum and its appendix, the vermiform process. Peri-
typhlitis signifies an inflammation of the connective tissues around
the cæcum. The terms typhlitis and perityphlitis are often used
indiscriminately, but they represent diseased processes in two distinct
classes of tissues, though their relations are so intimate that it is neces-
sary to consider them together. The cæcum is quite liable to any of
the diseases which may attack the intestinal canal, but it is only the
form of the disease here defined which presents any characteristic.
aspects or the nature of which is such as to require separate considera-
tion. Ulceration and perforation are secondary only to this condition,
and will also be considered under this head.
Etiology. This disease may not only be occasioned by the ordi-
nary causes which produce intestinal catarrh, but, owing to its pecu-
liar anatomical character and physiological relations, the cæcum is
especially prone to harbor the nuclei of irritating products. Any
foreign body, such as an intestinal or biliary calculus, or a grape-seed,
cherry-pit, or shot, or a hardened fæcal mass, becoming gradually
enlarged by the secretions or excretions which adhere to it, forms a
body which eventually resembles fruit-stone, and which is all-suffi-
DISEASES OF THE ORGANS OF DIGESTION.
713
cient to excite inflammatory action, possibly followed by softening
and perforation.
Pathology. The pathological changes may be essentially the
same as those found in catarrhal inflammation of other portions of the
mucous membrane. If the inflammation is limited to this locality
and results from the irritation of a foreign substance, the action is
intense, and ends in ulceration and consequent perforation. If this
should occur on the posterior wall of the cæcum, which is not covered
by the peritoneum, the intestinal contents escape into the surrounding
connective tissue, exciting inflammation, and resulting in the forma-
tion of a fæcal abscess. This abscess may point and discharge exter-
nally, or a fistulous communication with the intestine will be estab-
lished, which either remains permanently open, or gradually closes
and heals over.
Sometimes this condition of ulceration involves the entire cæcum
and appendix, converting it into a disorganized mass, with perforation
directly into the peritoneum, exciting a rapidly fatal peritonitis or a
local peritonitis with limiting adhesions, or else perforates the perito-
neum, resulting in abscess. In the latter case the purulent collection.
sometimes makes its way downwards under Poupart's ligament, along
the sheath of the femoral vessels; at other times it descends into the
pelvis, and perhaps opens into the rectum; or it points directly over
the crest of the ilium, or backwards towards the lumbar region, or in
other directions, though it is most apt to present itself as a lump
immediately over the site of the cæcum. This abscess may, accord-
ing to its course, burrow largely and cause extensive non-healing.
sinuses, or may discharge its contents at once, the orifice promptly
healing over. Inflammation of the cæcum may occur without the
presence of irritating products, and gradually assume a chronic form
without ulcerative tendency. In such cases the inflammatory action.
may extend to the adjacent connective tissue (perityphlitis), which
becomes thickened, and permanent stenosis results.
Symptomatology.-The symptoms of typhlitis are quite diverse
in their character, no two cases being distinctly alike, yet probably all
sufficiently typical for purposes of diagnosis. Sometimes a case is
ushered in with great intensity and without premonitory symptoms,
though, as a rule, the patient complains of more or less dyspeptic
symptoms, has considerable colic, and is troubled with an alternate
diarrhoea and constipation. The constipation soon becomes marked,
and the accumulated fæces form a distinct tumor in the right iliac
region, which is tender on pressure, and from which pains extend in
the course of the ascending colon and down the right thigh. Gases
begin to accumulate above the obstructed point, antiperistaltic move-
ments are established, and vomiting sets in, which consists at first of
the contents of the stomach, then of green bilious masses, and ulti-
+
714
A SYSTEM OF MEDICINE.
mately of stercoraceous matter. In case a favorable issue is to be
anticipated, the patient at this point has a copious and natural move-
ment of fæcal matter, the pains begin to subside, and the general con-
dition of the patient rapidly improves. Sometimes, on the contrary,
perforation takes place suddenly at this stage, and the patient passes
rapidly into fatal collapse. Again, the symptoms of an immediately
fatal collapse may not supervene. The local pain, tenderness, and
swelling continue to increase, the inflammation from the serous cov-
ering of the cæcum and ascending colon extends to the peritoneum of
the neighboring intestine and abdominal wall, and involves the con-
nective tissue, uniting the ascending colon to the iliac fascia. The
subsequent history is that of a peritonitis, or a perityphlitis is set up,
as shown by local redness, a firm swelling, oedema of the skin, increase
of pain and tenderness, with pains in the right thigh, or a feeling of
numbness and weight, occurring in paroxysms. The psoas and
iliacus muscles are infiltrated and cannot contract, so that the patient.
cannot raise his thigh. At the same time there are rigors and pyrexia,
followed usually by the signs of the formation of an abscess, which
may open in various directions, either externally or internally, some-
times thus exciting a peritonitis. In the last two types the dorsal
decubitus and the sitting posture are characteristic, the body being
turned toward the right side and somewhat flexed, in order to render
the abdominal muscles less tense and to relax the psoas and iliacus.
The symptoms may gradually improve, the secondary inflammations
disappear, the exudations become absorbed, and the patient slowly
recovers; or, more often, the inflammation of the peritoneum becomes
more diffuse, the exudation is not absorbed, hectic symptoms appear,
and the patient finally succumbs. When perityphlitis results in the
formation of an abscess, the pus has a fæcal odor and may be mixed
with actual fæces or intestinal gas. It consists mostly of purulent
masses mixed with degenerated connective tissue. If the abscess
escape externally or into the ascending colon, the patient, if strong,
may recover; but if the discharge takes place into the abdominal
cavity, the resulting peritonitis soon causes death. If inflammation
of the appendix occurs without implication of the cæcum, as is some-
times the case, the severe tenderness and pain do not exist in the
cæcum, but lower down, in the neighborhood of Poupart's ligament.
There is also pain in the groin, which extends down the course of the
anterior crural nerve and through the hip. The patient keeps the
thigh flexed continually, and every effort to straighten it is attended
with excruciating pain. In these cases the external tumefaction docs.
not appear, and intestinal movements are not interfered with, though
they increase the patient's suffering, as does even the passage of flatus.
Peritonitis is more likely to arise than in cases in which the cæcum
alone is involved.
DISEASES OF THE ORGANS OF DIGESTION.
715
We have now only to briefly consider the symptoms accompanying
ulceration of either the cæcum or appendix vermiformis, the latter
being most often the seat of the perforating ulcer. The nature of these
symptoms, however, is such that it is almost impossible to determine
whether the one point or the other is involved; nor does this practi-
cally affect the management of the case or its termination. While
ulceration and subsequent perforation are the chief causes of the peri-
toneal inflammation which accompanies typhlitis, yet, as has already
been seen, peritonitis may occur from contiguity of tissue without
ulceration and perforation having taken place; such cases, however,
are exceptional. Ordinarily, a rapid and diffuse peritonitis indicates
that ulceration has occurred and resulted in perforation.
Pain in the right iliac region is supposed to indicate ulceration of
the appendix, but it is quite difficult to satisfactorily settle the presence
of ulceration before the symptoms of peritonitis or perityphlitis are
manifest, for even then threatening, apparently pointing to perforation,
may occur in cases which ultimately result favorably. The tendency,
however, is to ulceration and consequent perforation; and the symp-
toms which are characteristic of this accident, particularly those of
collapse, rarely mislead.
The duration of typhlitis varies according to the severity of the
case. Mild cases may result favorably in a few days; more severe
cases run from two to three weeks, or terminate in peritonitis, follow-
ing the usual course of that affection. If perforation takes place into
the peritoneum, death usually results within a few days. If the
case assumes a chronic condition, with or without peritonitis or for-
mation of fæcal abscess, the duration is quite indefinite; it may cover
a period of months or years, or come to a suddenly fatal termination
at a comparatively early stage.
Diagnosis.-Typhlitis is most often distinguished from other affec-
tions of the bowels by the locality of the pain and the soreness and
swelling which accompany it. We may find it difficult to differentiate
between typhlitis and simple acute peritonitis, located in the right
ileum, or we may mistake the perforation occurring in typhoid for
that of cæcitis; in women, an inflamed cyst, or an extra-uterine preg-
nancy, or a cellulitis, may embarrass our diagnosis. Cancer at, or
near, the cæcum might present symptoms pointing in the direction
of typhlitis, but the presence of a nodulated tumor and the cancerous
cachexia would usually establish the nature of the existing dis-
ease.
Prognosis. Except in very mild cases, the prognosis is grave and
must be guarded. Under proper treatment a majority of cases recover,
but the final result in each individual case cannot be predicted with
certainty. Dr. Flint says that in none of the cases falling under his
716
A SYSTEM OF MEDICINE.
observation has perforation of the intestine taken place, and the ter-
mination has, in every instance, been favorable.*
Dr. Sands † has recorded the history of twenty cases of perityphlitis,
nineteen of which occurred in private practice. Amongst these, reso-
lution took place in seven; recovery after operation, eight; recovery
after rupture of abscess into bladder, one; recovery after rupture of
abscess into rectum, one; death after abscess had been opened, one;
death after unsuccessful attempt to reach the abscess, one; death with-
out operation (from secondary meningitis), one.
Niemeyer claims that typhlitis and its sequelæ do not often endanger
life, but we must hesitate to assume too much assurance of safety, for
at the best typhlitis involves grave and dangerous features which are
only to be avoided or overcome by the most careful and judicious
treatment.‡
Treatment.-Belladonna.-Great pain in the ileo-cæcal region; cannot bear
the slightest touch, even of the bed-covers; swelling and redness externally; nausea
and vomiting; lies quiet on the back, with limbs flexed; high fever with red face, hot
skin, and full, strong pulse.
Bryonia.-Ileo-cæcal region very sore and sensitive to touch; cutting or stitching
pains, especially on deep inspiration; worse from the slightest motion; after exuda-
tion has taken place; tongue white and dry; bowels constipated.
Hepar.-Ileo-cæcal region swollen, deep and hard, in a circumscribed lump;
threatening suppuration.
Mercurius.-Painful, hard, hot and red swelling in the ileo-cæcal region, painful
to the touch; face red, or pale and sickly; tongue red and dry, or white and flabby;
alternations of chilliness and heat; constipation, or frequent slimy discharges with
straining; sweat without relief.
Rhus tox.-Hard, painful swelling of nearly the entire right side of the abdomen;
pain worse on sitting, or when stretching out the right leg; lies on the back, with right
leg drawn up; great restlessness and uneasiness; constant desire to move, but cannot
do so on account of the pain it produces.
Also consult Ammonium, Arsenic, Colchicum, Colocynthis, Ginseng,
Graphites, Lachesis, Nitric acid, Nux vom., Opium, Phosphorus, Pla-
tina, Plumbum, Silicea, Sulphur, Zincum. If abscesses have formed:
Hepar, Graphites, Lachesis, Mercurius, Silicea, Sulphur.
Auxiliary Treatment.-Much attention must be paid to the
auxiliary measures in the treatment of typhlitis. Absolute rest is very
essential. The patient should be kept on a nourishing diet, which
should be soft and bland in its nature, so that the bowels may not be-
come overloaded by the fæcal residuum. Impaction should be pre-
vented, if possible, by the use of copious enemata of warm soapsuds.
Often, it will be found desirable to use a long rectal tube to convey
the fluid beyond the sigmoid flexure. Much benefit may be derived
by applying externally hot poultices of bread and milk, flaxseed,
slippery elm or cornmeal, or hot fomentations. Bartholow prefers the
* Clinical Medicine, 1879, pp. 282 and 310.
† N. Y. Medical Record, January 19, 1878.
+ Practical Medicine, vol. i., p. 578.
DISEASES OF THE ORGANS OF DIGESTION.
717
external application of ice, in an ice-bag, but this practice is not in ac-
cordance with the writer's experience.
When it is ascertained that pus is present, which may be accom-
plished early by the use of an aspirator, it should be evacuated at once
by an incision, and this incision should be kept open for free drainage.
The operation usually made for perityphlitic abscess is performed by
making an incision, two inches in length, parallel to Poupart's liga-
ment, over the centre of the tumescent region. After cautiously di-
viding the abdominal wall to the level of the fascia transversalis, the
hypodermic syringe is used to determine the exact locality of the ab-
scess. Then a deep incision, half an inch in length, completes the
operation. The wound should be kept open several days for drainage.*
COLIC.
BY A. C. COWPERTHWAITE, M.D., PH.D.
Definition. An intense twisting, griping pain in the abdomen,
occurring in paroxysms, and primarily without constitutional disturb-
It may occur secondarily as a symptom of different inflam-
matory affections of the abdominal viscera.
ance.
History. Many different conditions, mostly spasmodic, have been
termed colic, and have been described in text-books under that head
since very early times. It is, however, probable that the true intesti-
nal colic formed a large proportion of the cases occurring, and that it
was this affection to which most of the ancient writers referred. Even
at this day the term colic is used, erroneously, to indicate painful
disturbances of various parts,-the terms hepatic colic, nephritic colic,
and uterine colic only indicating sudden painful spasmodic affections
in these organs, the two former especially referring to the pain caused
by the passage of calculi from the liver and kidneys respectively.
Lead-colic, or painter's colic, also known as plumber's colic and
colica pictonum, is a distinctly different affection, and results from
lead-poisoning; being decidedly neuralgic in its character, it has been
considered under the head of enteralgia.
Etiology. The causes of colic are predisposing and exciting. In
the former, age, sex, temperament, and occupation figure as important
elements. Colic is more apt to occur in childhood and youth, also in
the female sex; it is more prone to attack persons of a nervous or a
lymphatic temperament, and those who are employed in sedentary
occupations. The exciting causes may be such as act either directly
upon the intestinal tract, or indirectly through the nervous system.
Of the former, the presence of some indigestible article of food or of
an excessive quantity of food in the bowels is the most common. Or-
* Dr. Sands in N. Y. Med. Record, January 19, 1878.
718
A SYSTEM OF MEDICINE.
dinary wind colic, or flatulent colic, so called, most often arises from a
decomposition of the contents of the intestines. Owing to peculiar
idiosyncrasies, certain varieties of food alway produce colic in certain
persons, but have no effect whatever on others. Exposure to cold,
especially when overheated, and excessive fatigue, often produce colic,
probably owing to the fact that these conditions interfere with the
functions of digestion.
Biliary derangements are said to produce colic, and under such cir-
cumstances the condition is known as "bilious colic," a faulty term,
as the supposed hepatic derangement may not have, and often has
not, any existence in fact. If biliary matters are vomited, and the
skin and sclerotic present more or less of an icteric hue, there may
be some reason for thus designating the affection. It is said that a
nervous diathesis and gouty and rheumatic conditions predispose to
colic, but it is probable that at least the former only favors the neural-
gic condition of the intestines known as enteralgia.
Pathology. As has been intimated, many authors consider colic
and visceral neuralgia identically the same affection. A difference be-
tween them is quite apparent, but it must be admitted that it is diffi-
cult to determine just what relation the paroxysms of pain in colic
bear to those which result from distinct nerve irritation, as in enteral-
gia. Probably, in enteralgia the nerve is irritated at its origin, while
in colic the irritation exists at the peripheral expansion. It is evident.
that the chief pathological feature of colic is spasms of the muscular
tube of the intestine, and this arises from direct or indirect irritation
of the peripheral extremities of the intestinal nerves.
The most common form of simple colic, designated as flatulent colic,
always arises from a decomposition of the intestinal contents, and in-
volves only a condition of distension. The contraction of the bowel
driving the incarcerated gas against a fæcal obstruction, or some other
hindrance to its exit, causes an accumulation which by its pressure
distends the intestinal wall and produces the colicky pains.
This condition, however, being entirely functional, leaves no traces be-
hind, and, unless colic has recurred in connection with some inflamma-
tory affection of the bowels, no pathological changes are established.
Symptomatology.-The essential feature of colic is an intense
pain in the abdomen, most frequently about the umbilicus but also
recurring elsewhere, and changing from place to place. This pain is
of a twisting, griping, or crampy character, and occurs in paroxysms
lasting a few minutes, passing off only to return with equal severity
after a more or less brief interval. During the paroxysms the patient.
is in great agony, groaning with the severity of the pain, and continu-
ally seeking relief by changing position or by pressing the hands or
some hard object against the abdomen. In most instances he bends
the body double, or draws up the limbs, or employs hard pressure to
DISEASES OF THE ORGANS OF DIGESTION.
719
mitigate the suffering; when this relief from pressure does not exist,
the presence of inflammatory condition may be suspected, although a
certain degree of soreness and of tenderness, especially in the cæcal
region, may be had without inflammatory action. In simple colic
the abdomen is usually somewhat bloated, and there is great rum-
bling and gurgling in the bowels, due to the moving about of fluid and
gaseous contents, caused by the irregular contractions which occur.
Nausea and vomiting are sometimes present, and constipation almost.
invariably so, a diarrhoeic stool, when occurring, usually putting an end
to the attack. In some cases the body is covered with a cold clammy
perspiration; the pulse becomes feeble; the voice hoarse, and the face
wears an anxious, frightened expression, thus simulating somewhat
an attack of cholera morbus. Usually the pulse is unaffected; it cer-
tainly never becomes full and rapid, a fact which also aids in exclud-
ing the presence of any inflammatory condition. The attack generally
lasts only a short time, sometimes a few minutes or hours, passing off
with a trifling diarrhoea or free discharge of flatus. In some cases
the attack persists for some time, owing to failure to dispose of the ex-
citing cause.
Varieties. A classification of the forms of colic is based upon the
presumable cause. Flatulent colic refers to that form of colic which is
characterized by an excessive accumulation of gas, the expulsion of
which affords relief. Colic is sometimes termed crapulous when it
arises from overeating or indigestion; verminous when it occurs from
the irritation of worms; stercoraceous when it is supposed to result
from the retention of fæces. Colic resulting from exposure to cold or
wet is supposed to involve a condition of the muscular coat of the in-
testines which is similar to that present in rheumatism, and is by some
authors termed rheumatic colic.
Diagnosis.-Colic may be distinguished from enteritis and from
peritonitis by an absence of the signs of inflammation, high pulse, high
temperature, and tenderness of the abdomen. In peritonitis, as in colic,
the patient is inclined to draw up the knees, but the absence or pres-
ence of the inflammatory symptoms establishes the diagnosis. Colic
not unfrequently precedes or accompanies various grave diseases and
structural lesions, and it is sometimes difficult to determine whether,
or not, the condition present is simply a functional affection; but by
a careful examination of the objective and constitutional symptoms
no serious error is likely to be made.
Prognosis.—The prognosis of uncomplicated functional colic is
invariably favorable, even though the attack be of the greatest severity.
When associated with other diseases, it is only a symptom, and
does not usually figure as an important element in the prognostic in-
dications.
Treatment.—The preventive treatment of colic consists principally
720
1
A SYSTEM OF MEDICINE.
in abstinence from food which tends to produce flatulence, especially
fruits and vegetables, and in protection against the ill effects of sudden
atmospheric changes; by the use of properly warm clothing, as flannel
worn next to the skin, at least over the abdomen, and due care in keep-
ing the feet warm and dry.
Therapeutics.-Colocynthis is the chief remedy. The pain is of a cutting,
twisting, griping, contractive character, mostly about the umbilicus, and makes the pa-
tient bend double; the pain is made worse by assuming any other position; great rest-
lessness and loud screaming on changing position; worse at intervals of five or ten
minutes; a discharge of stool or flatus affords temporary relief.
Dioscorea. Flatulent colic, severe cutting, griping pains about the umbilicus.
Worse on bending double, relieved by stretching the body out, or by walking about.
Chamomilla.-Flatulent colic of infants. Griping, tearing pain in the region
of the navel; abdomen distended with flatus. Child restless and irritable, only quiet
when carried.
Carbo veg.-Flatulent colic, abdomen full to bursting; worse from least food;
better from passing flatus.
Nux vomica.-Colic from indigestion. Griping, pinching pains, worse after
meals, especially after overeating, making the patient bend double. Especially useful
in debauchers; also in persons of sedentary habits who are subject to constipation and
hæmorrhoids.
Consult also Lycopodium (flatulent colic); Cina (colic from worms);
Cinchona (colic from gall-stones); Cocculus and Valerian (hysterical
colic).
Hot fomentations assist in affording relief, and a copious enema of
hot water is of great value, often removing the entire trouble at once.
In obstinate cases in which remedies seem of no avail, a few drops of
Chloroform will sometimes give immediate relief; Morphine should
never be used.
COLITIS.
BY A. C. COWPERTHWAITE, M.D., PH.D.
Synonym.-Colonitis.
Definition. An inflammation of the colon, supposed to be distinct
from dysentery.
Etiology.-Colitis may be caused by any of the factors which are
capable of causing inflammatory conditions in other portions of the
intestinal tract; it is especially liable to occur from exposure to cold
or from the presence of irritating substances in the colon.
Pathology. While colitis offers many features in common with
dysentery, the two conditions are nevertheless held to be essentially
distinct affections. In dysentery, the primary seat of the disease is in
the mucous membrane of the colon and rectum, while in colitis the
inflammation begins in the submucous tissue of the colon, the mucous
membrane being secondarily affected. The course of this disease is
usually rapid, however, and the mucous membrane becomes so soon
involved, and in a manner so identical with dysentery, that it is prac-
DISEASES OF THE ORGANS OF DIGESTION.
721
tically impossible to differentiate between the two, as it is also impos-
sible to detect any difference in the character of the structural changes
which occur.
Symptomatology.-In colitis the pains are mostly localized over
the affected part, and are of a colicky nature. There is present con-
siderable diarrhoea, the stools often containing mucus and pus;
distinct mucous and bloody stools and the violent tenesmus of dysen-
tery are not present unless the latter disease has been induced from
an extension of the inflammatory process through contiguity of tissue.
According to Leube,* if the disease assumes a chronic form, there is
usually an alternation of constipation with the diarrhoea; the patient
suffers also with meteorism, flatulence, dyspnoea, in consequence of
the impeded movements of the diaphragm; troublesome palpitation,
derangement of nutrition, resulting from lack of absorptive power on
the part of the intestines; uncomfortable feelings in the abdomen,
nausea, eructations, and sometimes even vomiting. The vomiting is
probably due, in most all cases, to a coexisting gastric catarrh, particu-
larly in those cases in which the entire mucous membrane of the
digestive tract is in a condition of passive hyperæmia and chronic in-
flammation, resulting from obstructed circulation, as in emphysema,
cirrhosis of the liver, etc. Finally, there is marked depression of
spirits, and even true hypochondria.
Diagnosis. The presence of an inflammation in some portion of
the intestinal tract is easily determined, but it is often difficult to ex-
actly locate the trouble. The localized pain and the mucous diarrhœa
without tenesmus speak strongly in favor of colitis, but these symp-
toms are so quickly followed by symptoms of true dysentery that we
are often left in doubt as to the primary trouble.
Prognosis. The prognosis in uncomplicated cases of colitis is
favorable; the presence of dysentery naturally modifies the prognosis.
Treatment. This is essentially the same as in dysentery, to the
article on which the reader is referred.
DYSENTERY.
BY A. C. COWPERTHWAITE, M.D., PH.D.
Synonyms.-Dysentery, Dysenteria, Flux, Bloody flux, Fluxus,
Tormina intestinorum, Colonitis.
Definition. An inflammation of the large intestine, accompanied
by tormina, followed by scanty mucous and bloody stools, straining
and tenesmus. The inflammation may involve only the rectum or
colon, or both, and may extend beyond the ileo-cæcal valve and in-
clude a portion of the small intestines, though this is rarely the case.
VOL. I.-46
* Ziemssen, vol. viii., p. 374.
722
A SYSTEM OF MEDICINE.
The disease is considered by some as a specific febrile affection, and
may occur sporadically or as an epidemic.
History.-Dysentery has been known since the earliest times, and
has ever proved one of the most fatal of scourges. It is especially
prevalent in tropical countries and in localities where there is a forced
abstinence from ordinary fruit and vegetable diet, coupled with ex-
posure and hardships. Even in temperate climates dysentery has
proved a formidable disease, but within the past few decades it seems.
to have lost much of its fatality, a fact largely due to improved
methods of treatment and to more systematic sanitary regulations.
Probably its less frequent occurrence than formerly in armies is due
to the same considerations, and to the fact that canned fruits and vege-
tables are now so freely used in army life, in the place of the old-time
diet of hard tack and salt meats, with occasional feasts on unripe or
decayed fruits and vegetables. Dysentery has received the attention
of all medical writers since the days of Hippocrates.
Etiology. Whether endemic or epidemic, we recognize both an
acute and chronic form of dysentery, the latter always originating from
the former. Those who consider dysentery a specific disease look for
its cause in a contagious specific poison, propagated from one indi-
vidual to another through the medium of the excretions and inhala-
tions, such propagation being favored by predisposing influences to be
described later as the general causes producing intestinal congestion
and inflammation. Such causes certainly produce sporadic dysen-
tery, and to what extent they are prime factors in the production of
the epidemic form, we may not know, though their influence is too
apparent to be rejected as at least predisposing elements in the causa-
tion of the disease. Recent investigations do not warrant the assump-
tion that dysentery is due to a specific contagion.
Dysentery is essentially a disease of hot climates and, when occur-
ring in temperate regions, it prevails in autumn when the days are hot
and the nights chilly, especially in persons much exposed to night air;
it also results from the use of impure water and unwholesome food,
from the former especially when it contains a decayed animal poison;
the emanations from decomposing animal and vegetable matter are
also fruitful causes. Bad ventilation, over-crowded rooms and filth
are prolific sources; it is on this account that it prevails so extensively
among soldiers and in jails and tenement-houses-anywhere, in fact,
where a large number of human beings are crowded together under
unfavorable hygienic conditions. Dysentery is said to be also of
malarial origin; at all events, it is especially prevalent in malarial
regions, probably on account of the congestion of the portal circulation
due to the paroxysms of ague.
Pathology.-Dysentery consists anatomically of an inflammation
of the large intestines, resulting in ulceration and exudation of the
DISEASES OF THE ORGANS OF DIGESTION.
723
mucous surface. Hyperæmia first appears, but the mucous surface
soon becomes very red and thickened, especially about the summits.
of the mucous folds, the solitary glands and mucous follicles becom-
ing quite prominent, and the membrane swollen and soft, and covered
with a mucous secretion which is by many looked upon as diphtheritic
or fibrinous in its nature. Some authors hold that it is catarrhal in
sporadic, and diphtheritic in epidemic, dysentery, which theory patho-
logical investigations seem to substantiate, although it cannot be ad-
mitted that dysentery possesses the contagious properties of diphtheria.
This theory may, however, account for the disease-producing proper-
ties of the intestinal excreta, for, no matter what our views may be
regarding the contagious character of dysentery, it is a well-established
fact that the emanations arising from dysenteric dejections propagate
the disease. The next step is disintegration of the mucous membrane,
which becomes gradually detached in portions, leaving a deep-red, con-
gested surface with ragged edges, which soon becomes the seat of an
ulcer, irregular in form, dark-colored and covered with a slough. The
fibrinous exudation is at first grayish or yellowish-gray, and covers
uniformly the entire mucous surface. This exudation consists of a
fibrinous substance with abundant granules, nuclei germs, epithelium
cells and young nucleated cells. The exudation partakes of the de-
generative process, and soon presents a dense parchment-like, unyield-
ing tissue which becomes gangrenous or is the seat of numerous rapidly
spreading ulcers. Sometimes the coats are so rapidly destroyed that
perforation takes place, but this is not usual. In such cases the peri-
toneum presents a dirty-gray discoloration, has lost its lustre, and, here.
and there, dilatation and injection of its capillary vessels is visible.
Should the disease terminate favorably, which it may do if the gangre-
nous destruction is not extensive, granulations spring up and cicatriza-
tion ensues, sometimes resulting in contraction, and leading to serious
consequences.
Sometimes there are found associated with dysentery enlargement,
redness, and softening of the mesenteric glands; serous inflammations,
especially peritonitis; hepatic abscesses due to embolic obstruction of
the portal veins, enlargement of the pancreas and spleen; extensive
bronchitis, or lobular pneumonia and pyæmic abscesses.
Symptomatology. The characteristic symptoms of dysentery,
and the symptoms which always indicate its presence, are griping
pains in the abdomen, followed by scanty stools of mucus and blood,
accompanied with much straining and tenesmus. Most cases are
ushered in with a preliminary stage, though the epidemic form may
begin suddenly and without warning, save a severe chill. The pre-
liminary symptoms are usually simple diarrhoeic stools, slight colicky
pains, thirst, and loss of appetite, the characteristic dysenteric symp-
toms developing gradually. Notwithstanding the severe and long-
724
A SYSTEM OF MEDICINE.
continued straining, the stools are scanty, and composed of mucus or of
mucus mixed with blood; sometimes, however, nothing but blood is
passed, and occasionally a few hard scybala accompany the evacua-
tion. The griping and tenesmus are at once relieved by the evacua-
tion, and pain only is felt after hard pressure over the region of the
colon; soon the griping pains return, and the scene is repeated, the
paroxysms and stools occurring in severe cases as often as every half
hour, and even much oftener, the general average being from ten to
twenty times in twenty-four hours. In some instances the stool affords
no relief; a burning pain in the rectum and a bearing-down sensation
in the hips remain, forcing the patient to continued but futile efforts.
to discharge what appears to him to be a foreign body in the rectum.
In mild cases these symptoms gradually disappear after three or
four days, no fever is developed, and the patient slowly recovers, the
convalescence being tardy from the dropsical conditions so apt to
supervene after mild cases, the blood being loaded with albumen. In
the severer cases, either sporadic or epidemic, at this stage the tem-
perature and pulse rise, the tongue becomes coated, the urine scanty
and passed with difficulty; there is considerable nausea and vomit-
ing, the bloody stools are more frequent and have a fetid odor; the
mucus in the dejections becomes a purulent fluid, and contains.
numerous shreds and flocculi, and occasionally masses of decompos-
ing sloughs of the mucous membrane, the stool often presenting the
appearance of scrapings from a hog's intestines. Sometimes the
evacuation from the bowels resembles water in which raw beef has
been soaked-a dangerous symptom,-at other times it is dark and
tarry, and highly offensive, especially when gangrene of the mucous.
coat of the intestine has set in. In fatal cases at this stage adynamic
symptoms are developed; the heart's action becomes feeble; the pulse
frequent, but weak and thready; the mind delirious, the mouth and
teeth covered with sordes, the stools are passed involuntarily, the abdo-
men is tympanitic, the skin cold, there is obstinate hiccough, and the
patient dies by slow asthenia.
If the patient recovers, the adynamia does not appear, or if so, in a
much less degree; the general symptoms gradually subside, the
evacuations become less frequent and contain less mucus and blood
and more feculent matter, and the patient slowly convalesces.
If the disease passes from the acute into the chronic form, as it
may, especially in hot climates, the fever subsides, the tenesmus and
other morbid sensations are less marked, the stools contain more fæcal
matter, often assume the form of an ordinary diarrhoea, but are not
always free from muco-bloody masses or a puriform fluid from the
ulcerated mucous membrane; the patient becomes very much emaci-
ated and anæmic; the features shrunken and distressed in appear-
ance; the skin dry and bran-like; the appetite impaired; the tongue
DISEASES OF THE ORGANS OF DIGESTION.
725
red and fissured; a hectic fever is developed, followed by night-sweats
and dropsical symptoms, and death finally ensues. If the patient
suffering from chronic dysentery recovers, as is sometimes the case,
he usually suffers more or less with chronic constipation and its
attendant evils for a long time.
Varieties.-Dysentery may be divided into sthenic, or inflamma-
tory, and asthenic, or typhoid forms; some authors add bilious, malarious,
malignant, and scorbutic, but subdivisions beyond the first mentioned
are impractical.
Diagnosis.-The symptoms of dysentery are quite characteristic,
and an examination of the stools, taken in connection with the sub-
jective symptoms, make the diagnosis of this disease a comparatively
easy matter.
It is sometimes difficult in the first stage of sporadic cases to dis-
tinguish it from diarrhoea, but dysenteric symptoms soon develop and
put an end to all such doubt.
Proctitis, or catarrh of the rectum, is sometimes mistaken for true
dysentery. In such cases the dysenteric symptoms are milder, and
the mucous stools never become foul, nor do they contain the shreds,
flocculi and gangrenous sloughs which occur in dysentery. Hæmor-
rhoids have been confounded with dysentery, but such a blunder
would be almost inexcusable.
Prognosis. The prognosis must be guarded in the first stages of
all cases, whether sporadic or epidemic, for we never know what to
expect, the general condition of the patient and the surrounding cir-
cumstances having so much to do with the development and course
of the disease. Sporadic cases usually recover, and a favorable prog-
nosis may be given in epidemic cases when they continue mild, or
even in severe cases when there is an absence of adynamia and the
signs of collapse. The most unfavorable symptoms are the gangren-
ous stools, severe hæmorrhage, a subsidence of the pain while the
other symptoms are growing worse, and suppression of the urine.
Protracted cases are most amenable to treatment, and usually recover.
Treatment. The possibilities of contagion render the prophylaxis
of this disease of the utmost importance. During the prevalence of
an epidemic all persons, whether directly exposed to the disease or
not, should adhere to a plain, nourishing diet, with a moderate quan-
tity of ripe fruit; they should be much in the open air, avoid expo-
sure and fatigue, wear flannel, at least over the abdomen, and eschew
unripe fruit and alcoholic stimulants.
During the early part of the disease the diet should be restricted to
a small quantity of light food, milk, eggs, custards, corn-starch, arrow-
root, mutton, oyster-soup, broth of mutton or beef, avoiding solid and
especially coarse foods. It is the aim to have as little residuum as
possible left to increase by friction the irritation of the mucous mem-
726
A SYSTEM OF MEDICINE.
brane. In case the symptoms denote a failure of the vital powers,
eggnog may be freely given in connection with a concentrated nour-
ishing diet of beef-tea, or something of a similar nature. In such
cases champagne may be used for the vomiting which is liable to be
present.
The apartments should be well ventilated and the sunlight be per-
mitted to enter; the patient should be sponged occasionally with tepid
water, and an enema is often grateful, using either warm or cold
water, as may prove most agreeable to the patient.
Injections of starch or flaxseed emulsion are a soothing application,
and cover the inflamed and irritable membrane of the rectum. If the
tenesmus is excessive, from five to ten drops of Laudanum may be
put into the starch or flaxseed injections to allay the irritability of the
muscular fibres. Especial care should be taken to remove the dejec-
tions at once from the room, not throwing them into the privy vault,
but into a separate pit, where they should be immediately disinfected.
The bed-pans, vessels, and syringes must not be used for other per-
sons, and all ordinary precautions must be taken to destroy the virus.
and to prevent the propagation of the disease.
The medicinal treatment of dysentery, unlike that of diarrhoea, is
confined within a small range of remedies. While many medicines.
outside of this range may occasionally be called for in individual cases,
it is rarely found necessary or desirable to employ them, as they are
very seldom indicated.
((
Mercurius, in its various forms, constitutes the chief remedy. Indeed, were
specific medication possible, we could agree with Bahr,* that the corrosive sublimate
corresponds to the symptoms of ordinary dysentery so perfectly that it may safely
be regarded as a specific for the whole process." Such a doctrine, however, is entirely
contrary to the spirit and teachings of homoeopathy; a specific for any disease does
not exist. Dr. Bell † says Merc. corr. "is too frequently employed in dysentery, to
which it is only applicable when occurring in great intensity and accompanied by the
characteristic urinary symptoms." The indications for its use are as follows:
Mercurius corr.-Stools frequent and scanty, composed of nothing but mucus
tinged with blood, or containing shreds of mucous membrane, like the scrapings of a
hog's intestines; offensive; accompanied by very distressing, persistent tenesmus, and
cutting, colicky pains; after stool, burning and tenesmus of the rectum and bladder.
Mercurius sol.-Dr. Dickensont says this remedy "is better adapted to spo-
radic dysentery, and is seldom indicated in malignant types." It is especially useful
in cases occurring from exposure to cool night air during hot weather. Stools com-
posed of green, bloody mucus, or of pure blood, and very excoriating; colic, burning,
and tenesmus before, during, and after stool; chilliness between the stools; the tenes-
mus and urging before and during the stool is rather increased after the stool—a con-
stant ineffectual urging, as if the patient would never get done, the pains sometimes
extending to the back. The abdomen generally feels cold, bad taste in the mouth;
tongue coated white, or swollen, soft and flabby; rheumatic pains in limbs; worse at
night.
Nux vomica.-After the abuse of diarrhoea-mixtures, or of alcoholic spirits,
and in persons of sedentary habits who are usually constipated, dysenteries of an inter-
* Science of Therapeutics, vol. i., page 463.
† Homœopathic Therapeutics of Diarrhoea, Dysentery, etc., page 123.
Homœopathic Principles and Practice of Medicine, page 151.
DISEASES OF THE ORGANS OF DIGESTION.
727
mittent type, constant disposition to stool, with inability to pass anything but a little
slimy, bloody mucus; small, hard, roundish lumps of fæcal matter, streaked with bright
red blood; tenesmus, relieved after stool; pressing pain in the back, as if broken, be-
fore and during stool.
Aconite. After suddenly checked perspiration from exposure to cold; attacks
occurring when the days are warm and the nights cool; first stage, with chill, high
fever, dry skin, thirst, restlessness; stools frequent, small, composed of bloody, slimy
mucus, with tenesmus, which is relieved after the discharge.
Arsenicum.-Stools of thick, dark green mucus; dark, bloody, watery, very of-
fensive, smelling like carrion or discharge from putrid ulcers; frequent; scanty; ex-
coriating; tenesmus and burning in the rectum and anus; great exhaustion after each
stool, and some short relief from the pain; great thirst, but drinking little at a time;
tongue whitish, fiery red, smooth, and dry, or dry and brown; nausea and vomiting;
face pale and sunken; great anguish and restlessness; pulse rapid and scarcely per-
ceptible.
Baptisia.-Dysentery with typhoid tendency; stools frequent, small, thin, dark,
fæcal, very offensive and acrid; pure blood; dark brown mucus and blood; tenesmus;
tongue dry, brown down the centre; sordes on lips and teeth; breath fetid; face
dark red, with a besotted expression; prostration more profound than the severity of
the attack would seem to justify.
Belladonna.-Especially useful in the dysentery of children; plethoric young
persons; stools greenish, slimy, bloody, with great tenesmus and urging; frequent;
scanty; tenesmus so severe as to cause shuddering; abdomen distended and very sen-
sitive to touch; tongue red and dry at the tips, or white in the centre, with red edges;
starting in sleep; stupor; delirium; face flushed; head hot while hands and feet are
cold; rolling head from side to side; throbbing of the carotids.
Cantharides. When complicated with irritation of the urethra and neck of
bladder, causing dysuria. White or pale reddish stools, like scrapings of the intes-
tines; or bloody watery, skinny, like the washings of meat; with stool: cutting in abdo-
men; after stool: shivering; violent burning pain through the whole intestinal tract;
distension and tenderness of the abdomen; thirst, but loathes any fluids; frequent,
painful, ineffectual urging to urinate, with burning after urination; collapse.
Capsicum.-Frequent mucous stools, mingled with dark blood; violent tenesmus,
and burning in both rectum and bladder; drawing pains in the back during stool,
which, with the tenesmus, are continued after stool; after every stool thirst, and after
every drink shivering; stool after drinking; abdomen enormously distended; taste as
of putrid water; pains aggravated by currents of air, even warm air.
Colchicum.-Autumnal dysentery. Stools of transparent jelly-like mucus, or
bloody mucus, containing large quantities of small, white membranous particles; vio
lent tenesmus; griping colic before stool, relieved after; constant ineffectual urging to
stool, owing to a spasm of the sphincter ani, with a shuddering on the back; prolapsus
ani; coldness and oedema of the legs; cramps in the calves; ascites; urine dark brown
and scanty; great prostration; aversion to the smell of food.
Colocynthis.-Mostly indicated in the first stages, with the characteristic pains.
Stools greenish, slimy and bloody, like scrapings of the intestines; renewed after the
least food or drink; abdomen bloated; violent pains in the abdomen, as though the
intestines were squeezed between stones, which compels the patient to bend double;
pain relieved after each stool; weakness, paleness, and great prostration after stool.
Ipecacuanha.—Antumnal dysentery. After eating unripe fruit, vegetables,
and sour substances. Stools of green mucus, green as grass; fermented; colic; per-
sistent nausea and vomiting; worse in the evening.
Nitric acid.-Subacute or chronic dysentery, especially when the bowels are
ulcerated and pus discharged; typhoid type with diphtheritic deposit on mucous
membrane of the intestines. After the abuse of mercury or in syphilitic patients;
green or bloody mucous stools; flakes of false membrane; putrid; fetid; acrid; tenes-
mus during stool, great exhaustion after.
Sulphur.-When other remedies have failed; especially useful after Aconite has
removed the acute symptoms; chronic variety; ulceration of mucous membrane.
Stools of blood-streaked mucus; fetid; slimy; excoriating; colic, straining, and violent
tenesmus; tenesmus continues a long time after the discharge; worse at night or in
the early morning; prolapsus ani; dryness of mouth and tongue; tongue coated white
with red tip and edges; nausea; vomiting; offensive odor of the body.
728
A SYSTEM OF MEDICINE.
Consult also Aloes, Apis, Alum, Argentum nitr., Arnica, Bryonia,
Carbo veg., Cinchona, Dulcamara, Hamamelis, Kali bichr., Lachesis,
Magnesia carb., Phosphorus, Pulsatilla, Plumbum, Veratrum, Zincum.
DIARRHEA.
BY A. C. COWPERTHWAITE, M.D., PH.D.
Synonyms.-Ileitis, Ileo-colitis, Catarrh of the ileum, and of the
ileum and colon.
Definition. By diarrhoea we understand a morbid frequency of
loose alvine evacuations, without tenesmus, the stools being otherwise
altered in character.
Diarrhoea may occur primarily as a functional derangement of the
small intestines, independent of inflammation or any pathological
state. Secondarily it occurs as a symptom of inflammation of the
intestines, and also of some functional affections, such as cholera and
dyspepsia, and accompanies certain grave constitutional diseases, such
as tuberculosis of the intestine, cancer, and typhoid fever. It may,
therefore, be considered a symptom rather than a disease per se, yet
occurring as a result of such a variety of causes, both local and con-
stitutional, that it merits special notice.
Etiology. Diarrhoea is practically the result of an irritation of
the mucous lining of the intestines. Of the agents which directly
produce this condition, we find indigestible foods, unripe fruits, and
impure or irritating drinks, as well as purgative medicines and irritant
poisons the most important ætiological factors; indirectly, the same.
condition may be produced from exposure to cold or wet, or sudden.
atmospheric changes, vicissitudes of temperature, and excessive fatigue;
in the same manner mental emotions often produce a functional diar-
rhoea. The writer knows of a young clergyman who, when about to
preach his maiden sermon before a large audience, was obliged to
hurriedly leave his pulpit and evacuate the bowels. Flint reports the
case of a surgeon who, when about to operate for hernia, was so over-
come by anxiety incident to his sense of responsibility, that he was
obliged to relinquish the scalpel and precipitately retire to evacuate
the bowels. Thus fright or anxiety are shown to be important causes
of a functional disturbance of the bowels.
Among the indirect causes of diarrhoea belong dentition, as well as
those constitutional disturbances which result in looseness of the
bowels as a secondary effect of systemic poisoning or exhaustion; to
the latter belong tuberculosis, pyæmia, albuminuria, cancer, gout, and
enteric fevers. Chronic malarial diseases and exposure to malarial
influences may also produce diarrhoea, and it may occur from expo-
sure to the emanations which arise from decomposing animal matter.
DISEASES OF THE ORGANS OF DIGESTION.
729
As a familiar instance of the latter, I would quote the diarrhoea so
frequently occurring in medical students while engaged in the dissect-
ing room. Diarrhoea may also result from a mechanical congestion
of the intestines, due to some obstruction in the portal circulation, and
from the rapid suppression of discharges, or the absorption of dropsical
fluid, or the disturbance of the functions of other organs, being in
such instances vicarious in its character.
Pathology.-Diarrhoea is a symptom rather than a disease in
itself, a morbid action of function, not a structural disease. Those
pathological states which induce diarrhoea, or with which it may be
associated, are discussed elsewhere. It may be stated, however, that
it is often quite difficult to determine whether the diarrhoea is purely
functional or whether it depends upon a slight inflammatory condi-
tion; it is certainly safe to say that the irritating causes which may
develop a functional diarrhoea are quite sure to develop more or less
congestion in the mucous surface, varying from a very slight degree to a
condition of subacute inflammation. An increased peristaltic action,
with increased transudation, and an excessive secretion from the
mucous follicles, with the varying degree of congestion named, are the
only pathological elements that may accompany a purely functional.
diarrhoea.
Varieties and Symptoms.--Nosologists have divided diarrhoea
into many varieties, founded upon the character of the discharge; these
divisions, though convenient, are nevertheless arbitrary, often mislead-
ing, and certainly of no practical use in the treatment of the disease.
In feculent or fæcal diarrhoea the stools are abnormally soft or liquid,
but not especially changed in their character, and have a normal odor.
Such cases may be painless or preceded by griping colicky pains,
usually relieved by the evacuations. A bilious diarrhoea presents a
yellow or green stool, the color supposed, somewhat rashly, to result
from an admixture of bile; here constitutional disturbances are more
marked. We find present: nausea, coated tongue, bad taste in the
mouth, headache, and, with the stools, scalding at the anus, and dis-
tinct, sometimes very distressing, griping pains, which are relieved by
the evacuation. This form of diarrhoea is undoubtedly due to de-
ranged biliary function, but is not diagnostic of any particular hepatic
disease. It is more apt to merge into an inflammatory diarrhoea or
dysentery than are the other varieties.
A serous diarrhoea has watery stools. They are usually copious, and
are accompanied by more or less constitutional disturbance, loss of
appetite, nausea, tenderness of the abdomen, scanty and highly col-
ored urine, quickened pulse, slightly increased temperature, griping,
gnawing pains, and other evidences of a subacute inflammatory con-
dition.
In lienteric diarrhoea the stools contain undigested aliment. This is
730
A SYSTEM OF MEDICINE.
essentially a diarrhoea due to atony, and differs distinctly from all
other varieties. The digestive, assimilative, and absorbent functions.
seem to be in a state of total suspension, and the food passes through
the alimentary tract in an unchanged condition. The appetite is
voracious, but the strength rapidly fails, and death may result. from
anæmia and exhaustion.
Any form of diarrhoea is termed colliquative when it produces a rapid
exhaustion of the system. Such may occur from extreme vicissitudes
of temperature, exposure, excessive fatigue, deprivation of food; in
women, from prolonged lactation; it is found in persons who are
anæmic, or who have become enfeebled from tedious chronic diseases,
there being no definite intestinal lesion. A more scientific division of
diarrhoea, as made by some authors, gives: (1) diarrhoea from irrita-
tion; (2) congestive or inflammatory diarrhoea;. (3) diarrhoea from
atony. The first variety includes all cases of feculent diarrhoea and
those which result directly from irritation of the intestines. The sec-
ond variety includes all cases caused by, or accompanying, an increased
vascular action in the intestinal mucous membrane, the cutaneous
eliminations of fluids being at the same time obstructed. Here are
included the cases which result from exposure to cold, from taking
ice-cold drinks while over-heated, from suppression of perspiration, or
of an accustomed discharge. The third variety includes the cases
which are usually described as lienteric, being characterized by undi-
gested stools. To these divisions other authors add (4) chronic diar-
rhoea, including the chronic forms of all the varieties heretofore men-
tioned, and which need not be recapitulated. There is, however, a
form of chronic diarrhoea, characterized by pale stools, and sometimes
known as diarrhoea alba, or white flux, which deserves a passing
notice. It is especially prevalent in India, but is not unknown to any
European nation, and is supposed to be due directly or indirectly to
the influences of malarial poisoning. The disease is very insidious
in its approach, the stools not being very frequent at first, and attract-
ing but little attention. The fæces are yellowish, or pale drab, or
whitish in color, the paleness increasing as the disease advances.
They also become more and more watery, gradually lienteric, and some-
times dysenteric in the latter stages. There may be present symptoms
of disturbed digestion. The tongue and mouth are sore and red, being
studded more or less with aphthous ulcers. The appetite is usually
lost, but may be capricious, sometimes voracious, and the abdomen is
distended with flatulence. The body becomes anæmic and emaciates
rapidly, dropsical swellings occur, and the patient finally dies from
exhaustion or in convulsions. Such indeed is the usual course of all
chronic diarrhoeas when they proceed to a fatal termination.
Diagnosis. It is an easy matter to diagnosticate a simple case of
feculent diarrhoea, but often quite difficult to distinguish between the
DISEASES OF THE ORGANS OF DIGESTION.
731
different forms of this disorder, and to establish the extent of inflam-
matory action, or to discover the pathological state which is respon-
sible for the diarrhoeic condition. The absence of pain, tenderness,
and fever excludes acute inflammation, and, as a rule, lesion of the
mucous membrane also. The latter, however, may be suspected when.
the diarrhoea follows a dysenteric attack or enteritis, or is of long
standing and resists all judicious treatment. A bilious diarrhoea may
easily be mistaken for dysentery in the first stages. If there is much
straining, and if, after washing the discharges, shreds of mucus are
found, with flocculent masses and strings adhering to the vessel, the
case is one of dysentery.
Prognosis. The prognosis depends entirely upon the extent and
character of existing constitutional disturbances. In simple diarrhoeas.
from irritation the prognosis is favorable; the same is the case in the
earlier stages of the inflammatory forms. Diarrhoea accompanying
tuberculosis or cancerous diseases, or occurring with long-standing
hepatic and splenic disorders, is a serious complication; the prognosis
of chronic diarrhoea is generally unfavorable, but with a proper regimen
and the carefully selected homoeopathic remedy, most cases may be
controlled.
Treatment. Since diarrhoea, in the great majority of cases, arises
from errors of diet and from careless habits, it is evident that few cases
of uncomplicated diarrhoea would occur if due care were exercised in
matters of diet, clothing, and regimen. In the treatment of this dis-
order the observance of sound hygienic and dietetic rules is of the
utmost importance; and, in fact, indispensable to the cure. In mild
cases of the feculent type, a light farinaceous diet, or an entire absti-
nence from food for a short time, is desirable. In all cases, uncooked
vegetables and green fruits are to be interdicted, though ripe fruits
may be eaten in moderation. As a rule, milk combined with farina-
ceous foods, such as arrow-root, and corn-starch, and broth, are the
safest diet; milk alone must be avoided. If the casein is found un-
changed in the stools of children, milk with limewater will sometimes
alone stop the diarrhoea. Chickens, pigeons, mutton, and eggs are
usually to be allowed. All tough meats, such as beef and pork, and
particularly veal, are to be avoided. Above all, the nature of the diet
depends very much upon idiosyncrasy. In chronic diarrhoea a more
nourishing diet is desirable, which must be graded according to the
condition of the stomach and the power of the digestive system. Pro-
tection from atmospheric changes is a very important item in all cases,
and to this end the patient should continually wear flannels next the
skin.
Light exercise and an abundance of open air and sunlight are im-
portant hygienic conditions. Often a change of climate is of great
benefit, especially from a damp and heavy atmosphere to a dry brac-
732
A SYSTEM OF MEDICINE.
ing air. A sea voyage or short trips on the lakes are often of great
benefit, and sometimes even cure well-marked cases.
Fæcal or feculent diarrhoea may require: Aconite, Esculus, Aloes,
Baptisia, Calcarea, Chelidonium, Colocynthis, Hepar, Iris, Leptandra,
Nux vomica, Podophyllum, Rheum.
Bilious diarrhoea: Aconite, Ethusa, Aloes, Arsenic, Chamomilla,
Cinchona, Cina, Colocynthis, Dioscorea, Ipecacuanha, Leptandra,
Mercury, Phosphorus, Podophyllum, Pulsatilla, Sulphur, Veratrum.
Serous diarrhoea: Aconite, Aloes, Apis, Arsenic, Baptisia, Bella-
donna, Bismuth, Calcarea, Camphor, Carbo veg., Colchicum, Colo-
cynth., Conium, Crot. tig., Dioscorea, Ferrum, Gratiola, Hyoscyamus,
Ipecacuanha, Iris, Kali bichr., Leptandra, Mercury, Natrum sul., Phos-
phorus, Phosphoric acid, Podophyllum, Pulsatilla, Rhus, Secale, Sul-
phur.
Lienteric diarrhoea: Ethusa, Aloes, Antimonium crud., Arsenic,
Calcarea, Chamomilla, Cinchona, Colocynthis, Ferrum, Graphites,
Hepar, Iris, Leptandra, Magnesia carb., Phosphorus, Phosphoric acid,
Podophyllum, Sulphur.
Colliquative diarrhoea: Arsenic, Baptisia, Bismuth, Carbo veg., Cin-
chona, Colchicum, Ferrum, Iodum, Iris, Mercury, Phosphorus, Secale,
Thuja, Veratrum.
Podophyllum is probably the most useful remedy, especially in the diarrhoea of
infants during dentition, and when occurring during hot weather. Stools changeable;
watery, with meal-like sediment; yellow, liquid; green, sour, watery; undigested; clay-
colored; chalk-like. Profuse, frequent, gushing, painless; preceded by griping colic;
worse in the morning. Prolapsus ani. Exhaustion. Rolling head during dentition
(hydrocephaloid).
Chamomilla.-Especially in children, during dentition; also in summer after
checked perspiration, or after eating undigestible food. Stools white, slimy, watery;
yellowish, like scrambled eggs; hot, small, frequent; smell like rotten eggs; sour.
Colic before or during stool, relief after. Child peevish and whining, wants different
things, but repels them when given; cries, and is only quiet when being carried.
Mercurius.-Diarrhoea occurring in damp, cool weather, or in hot weather,
with cool nights; from exposure to night air. Stools green, slimy, brownish, scanty,
occasionally streaked with blood; sour; corrosive. Colic, burning and tenesmus be-
fore, during and after stool; chilliness between stools.
Colocynthis.-Only required when the characteristic colic pains are present;
griping, twisting, cutting pains, bending the patient double, relieved by the evacua-
tion. Stools copious, fæcal, fluid, yellow, frothy, with discharge of much flatus;
aggravated by the least food or drink.
Cinchona.-Diarrhoea during or after severe or chronic wasting diseases ; from
exhaustion and debility, especially after loss of fluids (lactation, hæmorrhages, etc.);
from eating fruit. Painless, watery, undigested stools; worse after meals and at night;
tympanitis; colic before stool, great exhaustion after.
Ipecacuanha.-Especially in children, during dentition; in autumn, after
eating unripe fruit and vegetables. Stools green as grass, fermented, attended with
colic, and vomiting of a green, jelly-like mucus; persistent and distressing nausea.
Aconite.-Diarrhoea from cold or damp, or after checked perspiration; from
getting overheated; from getting wet; from anger or fright. In summer when the
nights are cool. Stools watery; green, like chopped herbs; scanty, loose, frequent.
In the beginning, with heat, thirst, hard, full and frequent pulse.
Æthusa.-In children, in summer and during dentition. Stools bright yellow
or greenish, watery. Intolerance of milk, which is forcibly ejected as soon as swal-
DISEASES OF THE ORGANS OF DIGESTION.
733
lowed; vomiting of curdled milk; stools or vomiting followed by exhaustion and doz-
ing; spasms, with clenched thumbs.
cus.
Aloes.—Stools bright yellow, pappy; watery, containing lumps of jelly-like mu-
Worse in hot, damp weather; early in the morning; after eating and drinking.
Want of confidence in the sphincter ani; rectum feels full of heavy fluid, which seems
to fall out without any exertion.
Arsenicum.-Diarrhoea of malarial origin, or after chilling the stomach with
cold substances; also in chronic diarrhoea. Stools of slimy, green mucus; bloody, wa-
tery; dark-colored, offensive; painless; offensive; acrid; involuntary. Burning in
anus and rectum. Vomiting after eating and drinking. Great restlessness and anguish.
Burning thirst, drinks often, but little at a time. Great prostration; emaciation; rapid,
scarcely perceptible pulse.
:
Calcarea ostrearum.-Children during dentition; fat, scrofulous children;
open fontanelles. Chronic diarrhoea. Stools white, chalk-like; undigested first hard,
then pasty, then liquid; offensive, like bad eggs; sour. Debility. Profuse sweat on
head when sleeping, wetting the pillow; feet constantly cold and damp.
Croton tigl.-Yellow, dirty green, or brown, watery stools, coming out like a
shot; worse while eating or drinking; while nursing.
Iris vers.-Stool profuse, thin, watery, tinged with bile, corrosive. Great burn-
ing in anus after stool, as if on fire; vomiting of an extremely sour fluid, which exco-
riates the throat; also of sour milk in children.
Magnesia carb.-Stool green and frothy, like scum of a frog-pond; white
masses, like lumps of tallow, floating on the green, watery stool; sour eructations, also
sour vomiting.
Nux vomica.-Diarrhea from high living; from abuse of alcoholic liquors;
after drastic medicines or prolonged drugging; alternating with constipation. Stools
dark-colored, brownish or greenish; frequent; small; corrosive; offensive; worse
mornings. Constant ineffectual urging. After stool, sensation as if more remained
but could not be evacuated.
Phosphorus.-Chronic and colliquative diarrhoeas. Stools painless, watery,
very debilitating; involuntary; gray, or whitish gray; watery, with lumps of white
mucus, or little grains like tallow; copious, like water from a hydrant; purulent; un-
digested; oozing from the constantly open anus.
Rheum.—In children, during dentition. Very sour-smelling stools; child smells
sour, even if washed or bathed; straining before stool, and colicky, constrictive cutting
in the abdomen after; shivering during stool.
Secale corn.-Protracted diarrhea in scrofulous children, during summer;
putrid, fetid, colliquative. Sudden attacks of involuntary diarrhoea in aged persons.
Stools brown; dark-colored; thin, olive-green. Aversion to heat or to being covered.
Sulphur.—Diarrhea from suppressed eruptions; after taking cold; in children;
scrofulous persons; during dentition; chronic diarrhoea. Early morning diarrhea,
driving out of bed. Stools watery; frothy, green, watery; fetid, slimy; pappy, green-
ish, yellow; excoriating; involuntary; sour; fetid; putrid. Offensive odor of the
body, the smell of the stool follows him, as if he had soiled himself. Aversion to wash-
ing. Excessive prostration and rapid emaciation.
Veratrum alb.-Violent, painful, copious, with profuse, cold perspiration,
especially on forehead. Greenish, watery stools, mixed with flakes: rice-water stools.
Severe pinching colic before and during stool, with nausea, vomiting, weakness and
shuddering; after stool, great sinking and empty feeling in stomach; hippocratic coun-
tenance; violent thirst for large quantities of very cold water or for acid driuks.
Also consult Esculus, Agaricus, Alum., Antimonium crud., Apis,
Argentum nit., Arnica, Asa fæet., Baptisia, Belladonna, Borax, Bovista,
Bryonia, Calcarea phos., Camphor, Cantharides, Capsicum, Carbo veg.,
Chelidonium, Cina, Colchicum, Conium, Dioscorea, Dulcamara, Ela-
terium, Gelsemium, Graphites, Gratiola, Helleborus, Hepar, Hyoscy
amus, Iodum, Kali bichr., Lachesis, Leptandra, Lycopodium, Natrum
734
A SYSTEM OF MEDICINE.
sulph., Nitric acid, Pulsatilla, Rhus, Rumex, Sepia, Silicea, Sulph:
acid, Thuja, Zincum.
Also, compare treatment of enteritis.
CHOLERA MORBUS.
BY A. C. COWPERTHWAITE, M.D., PH.D.
Synonyms.-Sporadic cholera, Cholera biliosa, Cholera nostras,
European cholera.
Definition. An acute catarrh of the stomach and intestines,
occurring in hot seasons, characterized by the suddenness of the
attack, which consists in violent vomiting and purging, and is usually
attended by cramp-like pains in the abdomen, spasms of the abdomi-
nal muscles, coldness, feeble pulse, and great prostration.
Ætiology.—Cholera morbus may be caused by exposure to sud-
den cool changes of temperature during the hot season, as, for instance,
passing from a hot room into a cool cellar, or getting wet wnen over-
heated. So, also, large draughts of ice-water, taken when overheated,
may produce the same result and in the same manner by arresting
suddenly the functions of digestion. It is, however, usually considered
that these causes, especially the former, are predisposing rather than
exciting, and that the chief exciting cause lies in the ingestion of cer-
tain indigestible articles of food, such as unripe fruit and vegetables,
decayed meat, etc., producing direct irritation or setting up a fermenta-
tive process in the stomach and intestines. Even as ancient a writer
as Galen attributed cholera morbus to the presence of acrid humors
generated by the corruption of food. It is thought by some that this
affection involves a special cause, the nature and source of which are
yet unknown.
Pathology.-Cholera morbus, being a functional disease, leaves.
few traces of its effects in the organism. These, if any, are similar,
except in degree of severity, to those of true cholera.
There may be evidence of gastro-intestinal catarrh; hyperæmia of
the mucous surface, desquamation of the epithelium, swelling of the
glands, thickness and prune-juice color of the blood, etc. The phe-
nomena of the disease may be explained on the ground that the
offending substance causes irritation of the gastro-duodenal lining
membrane, which excites a morbid transudation and produces the
vomiting and purging. The irritation then extends to the liver,
exciting in some cases the biliary secretion; and to the spinal cord,
causing cramps in the muscles of the abdomen and legs; and, finally,
to the sympathetic, producing, through the vaso-motor system, cold-
ness of the skin and capillary torpor.
Symptomatology.-Attacks usually occur suddenly, but may be
preceded for a few hours by weight and uneasiness in the epigastrium,
DISEASES OF THE ORGANS OF DIGESTION.
735
nausea, and some diarrhoea. The attacks occur most often in the
night; the patient is awakened by colicky pains and some chilliness,
and is almost immediately attacked with vomiting, first of the food
last taken, with gastric mucus and a little bile, afterwards of bile and
thin mucus alone. Almost simultaneously the purging sets in, first
of offensive fæcal, diarrhoeic stools, and later of mucus and bile. In
severe cases the discharges partake more nearly of the "rice-water"
character of true choleraic stools, being copious, thin, whitish, odorless,
or having a faint, mouse-like odor, consisting of blood and serum,
with mucus and casts of epithelium. The acts of purging are usually
preceded by pain in the abdomen, which is temporarily relieved by
the evacuation. These evacuations from the stomach and bowels are
quite copious and occur very rapidly, soon reducing the patient in a
remarkable manner, who is often so exhausted after one or two hours
as to be unable to rise from the bed. The abdomen becomes con-
tracted, and spasms of the abdominal muscles may occur; the body
becomes shrunken, the face hippocratic, the surface cold and some-
times bathed in a clammy sweat; the pulse grows small and weak,
the voice is husky and feeble, the tongue and breath cold; cramps
may occur in the feet and legs, and there is a great thirst for cold.
drinks, which are usually ejected as soon as swallowed. The course of
the disease is rapid, ending in prompt recovery, or a condition threat-
ening a fatal collapse develops within twenty-four hours. Happily,
however, the latter termination is extremely rare; usually, after a few
hours the vomiting and purging become less severe, finally ceasing
altogether, and the patient, though weak, is generally about on the fol-
lowing day, all the organs immediately resuming the normal exercise
of their functions.
In the few fatal cases which occur, the choleraic symptoms become
more marked and the patient dies in collapse within a few hours.
In some cases the intense symptoms of the affection give way after a
few hours to those of a subacute gastro-intestinal catarrh, and conva-
lescence is somewhat tardy, occupying several days. Sometimes, in
such cases, fever of a remittent type is developed, which may assume
a dangerous typhoid form, or an acute attack of diarrhoea or dysentery
may be established.
Diagnosis. The symptoms of cholera morbus are so characteristic
that an error in diagnosis is rarely made. The absence of an epidemic.
would exclude Asiatic cholera, and in the presence of the latter a
technical diagnosis would be of little moment, as the diseases are
essentially the same, differing only in degree.
It is sometimes important to distinguish between cholera morbus
and cases of poisoning from acrid or corrosive substances. In the lat-
ter, there is burning in the throat and stomach before, as well as after,
vomiting has commenced, and the vomiting precedes the purging,
736
A SYSTEM OF MEDICINE.
whereas they are simultaneous, or nearly so, in cholera morbus, and
the vomiting is out of all proportion to the diarrhoea. There is more
gastric distress and tenderness and burning pain in the abdomen,
neither of which are relieved by the evacuation of the bowels. The
matter voided is apt to be bloody, and there are often bloody dis-
charges from the bowels, neither of which occur in cholera morbus.
Finally, poisoning may occur in any season of the year, while cholera
morbus is limited to certain seasons, and the concomitant circum-
stances will serve to allay or excite suspicion so far as poisoning is
concerned.
Prognosis. The prognosis is almost uniformly favorable, but
fatal cases occasionally occur, usually in persons already weak from
some other disease. Death may occur within twelve, but oftener after
twenty-four or forty-eight, hours. The indications for an unfavorable
issue have already been noticed.
Treatment. Cholera morbus seldom occurs in persons who
during the heated term exercise prudence in the selection of their diet
and are careful to avoid sudden changes of temperature; the wearing
of flannel next the skin is one of the best safeguards against cholera
and other bowel diseases occurring during the heated term. Persons
not desiring to wear flannel over the entire body should at least wear
a flannel bandage over the abdomen, especially if they are some-
what predisposed to acute disorders of the gastro-intestinal functions.
During the attack cold drinks should be limited; it is much safer
to allow the patient occasional small pieces of ice to be dissolved in
the mouth. If there is great prostration, a little brandy and water
may be of service. Sometimes iced champagne will be retained when
everything else is rejected. It is a good plan to give a little alcohol in
arrow-root or scalded milk, but whatever is given by the mouth
should be given in small quantities. During convalescence, and for
a few days after, the diet should be guarded. Mutton-broth or
chicken-broth, from which the fat has been removed, and light farina-
ceous foods, with toast, must precede a more substantial diet.
Veratrum album is the remedy most often indicated in this affection.
There is violent vomiting and purging, the stools being light-colored, or resembling
rice-water discharges. There is extreme exhaustion and copious perspiration, espe-
cially on the forehead; the body is cold; the face pale, cold and sunken; the pulse
feeble, but rapid, and there are present violent, cutting, griping colicky pains about
the umbilicus, as if the intestines were twisting in a knot, relieved by the stool.
Camphor is the remedy next in importance. It is indicated when cramps in
the muscles of the abdomen and of the arms and legs predominate, the vomiting and
purging being mild or entirely absent. There is great prostration, coldness, and ten-
dency to collapse. I find Camphor most useful in those cases resulting from cold. It
may be used by pouring a few drops of the tincture on some sugar, and dissolving this
in a third of a glass of water, giving a teaspoonful of the solution at a dose. The
Camphor cannot be given in water without the aid of sugar, which acts as a catalytic
agent.
Podophyllum is an excellent remedy when the vomiting and pain are not
DISEASES OF THE ORGANS OF DIGESTION.
737
severe, or are entirely absent, and the stools are profuse, watery, yellow, and of an of-
fensive odor.
Ipecacuanha is indicated in the milder class of cases when the discharges
are green, and the vomiting and retching are very severe, being out of all proportion
to the other symptoms.
Arsenicum album is not useful at the commencement of the disease, but
when after several hours the pains in the stomach and bowels become very severe,
burning or cutting in character, and are accompanied by intolerable anguish and
extreme restlessness, this remedy is most valuable. In such cases there is usually
extreme thirst, the smallest quantity of water aggravating all the symptoms; also
embarrassed respiration, weak, almost imperceptible pulse, icy coldness of the skin, and
clammy sweat, with subjective heat. It is especially indicated if the lips and tongue
become dry, black, and cracked, and when the stools become dark-colored and offensive.
Aconite, Colocynthis, Cuprum, Dioscorea, Cinchona, Iris vers., Nux vomica,
and Phosphorus may also be consulted.
Frequently, the use of hot fomentations over the abdomen will
afford much relief, and the domestic plan of giving the patient a hot
pack or bath, in order to produce a profuse warm perspiration over the
entire body, often proves very serviceable.
CHOLERA INFANTUM.
BY A. C. COWPERTHWAITE, M.D., PH.D.
Synonyms. Summer complaint, Gastro-enteric catarrh, Summer
cholera of infants.
Definition.—An acute gastro-intestinal catarrh, occurring in chil-
dren during the hot season, and especially during dentition, and char-
acterized by purging of a serous fluid, vomiting, high temperature,
rapid prostration, emaciation, and collapse. Some writers see fit to
include under this head that more frequent affection of infancy, en-
tero-colitis, or enteritis folliculosa, which has been elsewhere described.
While the latter disease presents many features in common with
cholera infantum it is an essentially distinct affection, and is ín no
sense a choleraic disease. On this point Duncan says, that "A
distinction should be drawn between what ought to be called cholera
infantum and that affection which is properly styled simple inflam-
matory diarrhoea or entero-colitis. Many physicians are in the habit of
distinguishing the various intestinal disorders of children so frequent
during the summer months under the common title of cholera infan-
tum. It is certainly evident that a large majority of the deaths reg-
istered in our mortality-returns under this title are the result not of
a true choleraic disease, but rather of entero-colitis, a disease of very
frequent occurrence, almost solely during the summer months in young
and, generally, teething children, who have been previously healthy,
or subject for a long time to simple diarrhoea."
History. Cholera infantum has been supposed by many to be a dis-
ease peculiar to America, but while it is probably particularly prevalent
* Diseases of Infants and Children, vol. i., p. 401.
VOL. I.-47
738
A SYSTEM OF MEDICINE.
in this country, it has been seen and described by many foreign authors.
Even Sydenham speaks of a sort of “cholera morbus exceedingly fatal
to infants;"* and later writers in France, Germany, Russia, and Eng-
land, have given it a more or less full description, while Lumbard
claims that Berlin surpasses American cities in the frequency of this
disease.†
Etiology.-Age is certainly a positive factor in the production of
this disease, as it rarely occurs after the second year, and more often
during the first eighteen months of life. At this age there is great
functional activity and rapid development of the intestinal follicles,
which is usually considered the predisposing cause for cholera infan-
tum. Many are disposed to refer the prevalence of cholera infantum
during infancy to the irritation of the first dentition. This, indeed,
must be considered as an important predisposing cause, yet we should
bear in mind that the process of teething is in itself a normal physio-
logical process, and it is not at all likely that we should ever have occa-
sion to enumerate the irritation of teething as a cause of this disease
could other causative agents be removed. Teething, nevertheless, in-
volves certain disturbances of the healthy equilibrium, holding the
organism in a peculiar state of susceptibility to certain external im-
pressions which render the system more particularly liable to be
overcome by their pernicious influences. A continuously high tem-
perature is one of the chief causes of cholera infantum.
In the city of New York, during a period of eleven years, out of
1245 deaths from cholera infantum, 1061 occurred in July, August,
and September; statistics have since shown a still greater portion oc-
curring at that time of the year. High temperature alone, however, ist
not responsible for this remarkable showing, for the disease is largely
limited to cities and large towns, and is more prevalent in the northern
and middle, than in the southern, states. It is therefore certain that
anti-hygienic influences, bad air and improper food, in addition to a
high temperature, are necessary to the production of cholera infantum.
Badly ventilated and over-crowded, ill-kept houses, and air contami-
nated by animal and vegetable decomposition and emanations from cess-
pools and sewers are potent causative factors. Aitkin says: "The chief
haunts of cholera infantum are the fever nests and cholera fields of
large towns. Diphtheria, scarlet fever, putrid sore throat, typhus and
Asiatic cholera herd together and fester in the slums, where the
wretched and squallid dwellers are stowed away in ill-ventilated, ill-
drained underground cellars and tenement houses, in the midst of
every possible insanitary condition, breathing a septic atmosphere,
* Works of Thomas Sydenham, M.D., Processus Integri, ch. xxiv., vol. ii., p. 267,
Syd. Soc. ed., London, 1850.
+ Traité de Climatologie Médicale, vol. iv., p. 317, Paris, 1880.
† Science and Practice of Medicine, vol. i., p. 637.
DISEASES OF THE ORGANS OF DIGESTION.
739
poisoned without by the putrilage of slaughter houses, soap and glue
factories, cesspools and sewers, and within by emanations from the
body, filthy clothing and bedding, and often the excrements of man
and beast."
High temperature, bad hygienic conditions, and the direct irritation
resulting from the use of improper food are the trio of causes which
combine to produce this scourge of infancy. Infants brought up by
hand and those just weaned furnish a very large proportion of the
victims; this is especially the case in cities where a supply of pure
milk is not easily obtained, even if the importance of it is fully appre-
ciated. On the other hand, ill health on the part of the mother affects
her milk, and unfits it for the use of the child; if the mother suffers
from devitalizing or septic influences, as she often does, the milk
secreted by her is imperfectly elaborated and likely to prove quite as
serious and exciting cause of intestinal disorder as an artificial diet.
Parents are sometimes imprudent enough to give infants unripe fruit
and vegetables, or allow them to eat from the table a variety of food
scarcely fit for the use of an adult. Such habits impair the digestion
of the child, and only too often excite cholera infantum or other
disorders of digestion.
Pathology. The pathological changes occurring in cholera in-
fantum are by many described to be identical with those present in
intestinal catarrh. This teaching arises from the fact that cholera
infantum has been so long confounded with entero-colitis that patho-
logists have accepted the conditions which are characteristic of the
latter as characteristic of cholera infantum. Frequently also, as stated,
follicular inflammation is associated with, or follows, cholera infantum,
and post-mortem examination will reveal the anatomo-pathological
changes characteristic of the former condition. In true choleraic dis-
ease the mucous membrane of the small intestine is found congested,
covered with mucus or a membranous exudation, and the follicles
are enlarged, softened, and sometimes ulcerated. Even here are rec-
ognized the evidences of follicular inflammation. But in the choleraic
condition there is underlying these manifestations a morbid condition.
of the blood, probably arising from defective nutrition, and a conse-
quent derangement of the sympathetic nervous system which does not
exist in a purely inflammatory affection.
Symptomatology.-Cholera infantum may be ushered in sud-
denly, or be preceded for an indefinite period by premonitory symp-
toms. In the first instance the symptoms closely resemble those of
the sporadic cholera of adults. The child, when in full health, and
without warning, is attacked with vomiting and purging which occur
in frequent paroxysms of great violence; after the contents of the
stomach and bowels are expelled, the abundant evacuations consist of
secreted or transuded liquid of a greenish or yellowish color. These
740
A SYSTEM OF MEDICINE.
symptoms may last but a few hours, and a recovery may speedily
ensue under proper homœopathic treatment. If this is not the case,
the vomiting and purging continue; there is great thirst, with inability
to retain water; the child utters sharp cries as if in great pain, the
surface becomes cold, the pulse rapid and weak, prostration ensues,
and an early collapse follows, death occurring in from one to three
days.
In other cases the choleraic symptoms may be preceded for several
days or weeks by a diarrhoea, which is not of a character calculated to
excite alarm. Suddenly the evacuations become frequent and watery,
being so thin as to soak into the napkin, leaving a greenish or greenish-
yellow stain, and having a peculiar, musty, offensive odor. They may
also contain particles of undigested food, milk curds, and yellowish.
masses of mucus which turn green on exposure. At the same time
vomiting of a sero-mucous fluid sets in, and everything taken into the
stomach is rejected immediately, whether it be water or the nurse, the
ejected matter frequently containing bile. There is excessive thirst;
the tongue at first is moist and usually clean, or covered with a light
fur; pulse is quite rapid, and at first full, but soon grows weak, running
from 140-160 beats per minute. In the early stages the temperature
of the body is natural, or very slightly raised at times, but the tem-
perature at the surface soon becomes reduced. The stools are often
painless, but usually the child whines and is restless before the evacua-
tion occurs, as if it were in pain, and frequently the face shows a dis-
tressed expression by a line extending from the labial angle to the
inside of the alæ nasi, and sometimes surrounding the orbicularis.
Not unfrequently the abdomen is hot and more or less tympanitic; at
other times it is cool and retracted, and is usually tender upon pres-
sure along the track of the colon.
The number of stools vary from four or five to twenty, or even more,
in twenty-four hours. The severity of the case is not always depend-
ent upon the frequency of the stools, the infrequency of their occur-
rence being often offset by excessive amounts, which drain the body
of its fluids at a more rapid rate than more frequent evacuations of an
ordinary quantity. The urine may become very scanty, and in severe
cases it is sometimes entirely suppressed. Often an aphthous condi-
tion of the buccal cavity occurs, and an erythematous rash diffuses
from the anus over the buttocks and genitals, causing so much tender-
ness that the contact of the irritating discharges excites pain. The
emaciation is rapid and extreme. In a few days the body shrinks,
the eyes are sunken and half-closed, the mouth remains partially open,
the lips are dry, cracked, and bleeding, the cheeks hollow, and the
face appears shrunken and pallid. The child now lies in a torpid
condition, is insensible to external impressions, is only temporarily
aroused by considerable effort, and apparently suffers only from the
DISEASES OF THE ORGANS OF DIGESTION.
741
distressing thirst which continues to the last. Even when indifferent
to all else, and seemingly unconscious, when water is offered the child
will raise its head, seize the cup, and drink with avidity. The body
becomes cool and is covered with a clammy sweat, the eyes are bleared,
and the pupils contracted. The pulse continues to increase in rapidity,
and becomes more and more feeble; the respiration is accelerated and
shallow from pulmonary congestion; carbonic acid poisoning ensues,
producing a comatose condition which ends in death. Not unfre-
quently, before death, slight convulsions and other symptoms of cere-
bral disturbance supervene, which may result from uræmic poisoning
or from that expression of cerebral anæmia which Marshall Hall de-
scribes under the term Hydrocephaloid, in contradistinction to acute
hydrocephalus, an inflammatory disease which it simulates, and for
which it is sometimes mistaken. In such cases the child grows rest-
less, utters sharp, plaintive cries, rolls its head from side to side, gradu-
ally falling into a comatose state, which becomes more and more pro-
found until death ensues.
If the termination is fatal, death usually occurs within three or four
days. When recovery takes place, the duration of the disease is from
two or three days to as many weeks, and sometimes inflammatory
complications, usually entero-colitis, will prolong the difficulty in-
definitely.
Diagnosis. The symptoms of cholera infantum are so character-
istic that the disease is easily recognized. The choleraic symptoms-
profuse watery stools, severe vomiting, thirst, rapid sinking and emaci-
ation, are sufficient to distinguish it from other forms of diarrhoea; and
the seasons of the year at which it occurs, the age of the patient, and
other surroundings, will serve to distinguish it from meningitis or any
primary cerebral disorder. During the prevalence of Asiatic cholera
it is often impossible to establish the identity of cholera infantum, but
as the indications for treatment are similar, and do not depend upon
the essential nature of the disease, the differential diagnosis is not of
unusual importance in the treatment.
Prognosis. The prognosis should always be guarded, and never
unqualifiedly favorable. Even when the disease is apparently sub-
dued, and the patient appears convalescing, the affection may continue.
as an enteritis, and ultimately prove fatal.
The hygienic conditions to which the child is subject have much to
do with the result, and the nature and quality of its nourishment is
an important item. Cholera infantum rarely occurs in a child nursing
from a healthy breast, and when it so occurs the prognosis is much
more favorable than in a bottle-fed child, or in one recently weaned.
The disease must always be considered dangerous and the result
doubtful, even though children seemingly hopelessly ill have made a
good recovery.
742
A SYSTEM OF MEDICINE.
According to Hartshorne, the bad signs in cholera-infantum are ex-
treme restlessness and jactitation, or, on the other hand, early apathy,
stupor, or convulsions; incessant and uncontrollable vomiting; exces-
sive frequency and copiousness of the discharges from the bowels; a
pinched "Hippocratic" countenance, and coldness, with a blue and
shrunken appearance of the extremities.
Encouraging symptoms are cessation of vomiting and diminution.
in the frequency and quantity of the discharges; quiet natural sleep;
even temperature of the body and limbs; diminution of thirst, and a
return of appetite and capacity for the digestion of food.
Treatment. No disease offers better opportunities for, and greater
encouragement in, the exercise of prophylactic measures. The child
that is well fed, kept clean, removed from the ill effects of bad venti-
lation and sewer-gas, and not exposed to extreme heat, rarely has
cholera infantum. When the mother's health allows, the child should
not be weaned until after the second summer, as that is the most
dangerous period of its life. If weaning before that time is unavoida-
ble, it should always be accomplished before the heat of summer
commences. The diet should then be pure fresh milk, kept perfectly
sweet, judiciously accompanied by farinaceous foods. Meat, in any
form, or fruit and vegetables should not be allowed until after the
first year of age is passed, and even then they must be used sparingly,
prepared with the utmost of care.
The child should be in the open air much of the time during the
day, avoiding the early morning and late evening air as well as the
intense heat of the noon hours. When the weather is at all cool or
damp, flannel should be worn next the skin.
The first measure to be adopted after the invasion of the disease is
the removal of the patient to some high, open, healthy locality, away
from the influences which may have given origin to the trouble. The
sea-shore or some mountain-resort is most desirable, or any moder-
ately elevated locality in the neighborhood may answer, always keep-
ing in view the necessity of a supply of pure water and of good fresh
milk. Those who cannot afford such a change should take the more
pains to keep the child in the open air and sunlight, with the restric-
tions above given. Frequent and long rides in the baby-carriage, or,
still better, boat-riding are of much value to the patient. In some
cities arrangements are such that children may be kept on a steam-
ferry or excursion-boat most of the day, and the result is decidedly ben-
eficial. When this is not to be had, the poor may make good use of
the public parks by keeping their sick children in them for a good
portion of the time.
Diet is next in importance; the quantity and quality of the food
must be painstakingly watched. Mother's milk, if healthy, is unques-
* Reynolds's System of Medicine, vol. iii., page 255.
DISEASES OF THE ORGANS OF DIGESTION.
743
tionably the most desirable food; in its absence, a healthy wet-nurse
should be secured, if possible. Failing in this, fresh cow's milk may
be used, which is to be properly diluted with boiling water, lightly
salted, and sweetened with loaf or milk sugar. Cow's milk may also
be diluted with barley-water and lime-water, the latter having a ten-
dency to correct the acidity of the stomach usually present. When
possible, it is best to use milk from only one cow, and a new cow is
better than one that has been giving milk for a long time. When pure
milk cannot be obtained, a reliable brand of condensed milk may be
used. Especial care must be taken to insure the absolute cleanliness
and sweetness of the vessel which contains the milk, and the bottle
from which the child is fed should be thoroughly cleansed and scalded
after it has been used. In cases in which milk does not agree, on ac-
count of the child's inability to digest the casein, barley-water may be
used, to which a small quantity of sweet cream must be added. Some-
times a change to farinaceous food is desirable, though such a change
involves a certain risk. Boiled or browned flour, Graham flour or oat-
meal, thoroughly cooked and largely diluted with water, arrow-root,
and gelatin often prove useful. Frequently the child craves an animal
diet, and in children over a year old this craving should not be disre-
garded. Chicken-broth, from a fully-grown fowl, or mutton-broth, or
a small piece of tender, broiled steak or mutton-chop may be allowed.
I have personally witnessed the good effects obtained from the use of
raw meat in this as well as other forms of intestinal disease. Tender
beef is most desirable, but if the child prefers chicken or mutton, they
may answer as well. Trousseau, who recommends raw meat highly,
suggests that it be finely hashed or, still better, reduced to a pulp in
a mortar, and pressed through a fine sieve, so as to separate the vessels
and areolar tissue. If the child manifests an aversion to it as thus
prepared, the hashed meat or pulp may be rendered palatable by the
addition of salt, sugar, or some kind of preserve, or it may be added
to a broth made with sago or tapioca. The only objectionable feature
in this diet is the danger of infection with tænia, but in severe cases
this danger cannot be taken into consideration. The beef peptonoids
manufactured by Reed and Carnrick may prove of excellent service.
Water may be allowed frequently, though not in large quantities; but
it is much better to have the child suck small pieces of ice, which are
very grateful and relieve the intense thirst without creating so much
irritability of the stomach.
Stimulants are sometimes useful. A weak wine-whey, or white of
egg beaten up with barley-water, to which a few drops of brandy or
whiskey have been added, will often prove desirable. A few drops of
pure brandy, given in a small quantity of ice-water, may check the
vomiting and lessen the abdominal heat.
* Trousseau's Clinical Medicine, vol. ii.
744
A SYSTEM OF MEDICINE.
Proper bathing is a matter of considerable importance, especially at
the outset of the disease. Warm baths, as a rule, are more efficacious,
but Ziemssen, and others, especially recommend a cool bath-from 65°
to 85°. The child should be introduced into the water at the highest
point named, and the temperature of the bath gradually reduced by
the addition of cold water. The bath may continue for five or ten
minutes, and be repeated two or three times a day, according to the
height of the temperature. During convalescence an occasional salt
bath is desirable; it must be cool enough to be grateful to the child.
without causing chilliness. Of course, sea-water bathing is preferable
when available. In the later stages the child is too much exhausted
to endure the fatigue and irritation of the bath, and only sponge-bath-
ing should be had. In case there is coldness of the extremities and
of the ears and nose, as is often the case, artificial heat must be applied.
This can be done by wrapping the child in hot flannels, and by placing
to the feet a hot brick or a bottle filled with hot water.
It is the opinion of the writer that the gums should never be lanced
unless the membrane is so tense over the tooth as to leave the latter
exposed after the lancing. I think the greatest irritation from denti-
tion occurs before the teeth come within reach of the lancet, and to
lance the gums under such circumstances is productive of no good,
and possibly much harm.
Therapeutics.-Veratrum album is, in most instances, the first remedy to
be used. It is indicated by the suddenness of the attack, the copious watery stools, the
violent and excessive vomiting, the cold, clammy perspiration, especially on the fore-
head, and the great exhaustion following each attack of vomiting and purging. The
hirst is great, but each drink excites vomiting; the tongue is cold, the pulse almost.
imperceptible, the face hippocratic.
Ipecac.-Nausea and vomiting predominate; stools green as grass, or fermented
like yeast; face pale and puffed, or sunken; blue rings around the eyes.
Podophyllum.-Stools frequent, painless, watery, gushing, fetid or sour; yellow
or green; often changing in their character, and usually worse in the morning. Es-
pecially during dentition, when the head is hot and is continually rolled from side to
side.
Arsenicum.-Stools green, or dark, watery, offensive; violent and incessant
vomiting of a brown substance, or of mucus and blood, excited by drinking; great
thirst, but drinks only a little at a time; great restlessness and prostration; much
emaciation; hippocratic face; cold extremities; distended and tympanitic abdomen.
More useful in the later stages of the disease.
Camphor.-Choleraic symptoms; collapse threatening; skin cold, yet the child
will not remain covered; little or no vomiting and purging, great prostration and cold-
ness.
Cuprum.—Painful green stools; forcible vomiting or violent ineffectual efforts
to vomit, relieved by drinking cold water. Especially when there is a tendency to
convulsions from the beginning. Hydrocephaloid.
Iris versicolor is a valuable remedy. Stool thin, watery, copious, bilious;
vomiting of a sour fluid, or of soured milk; much pain and burning distress in the epi-
gastrium.
Consult also Aconite, Ethusa, Belladonna, Borax, Calcarea, Chamo-
milla, Cinchona, Croton tigl., Ferrum phos., Kreosote, Magnesia carb., Mer-
curius, Phosphorus, Silicea, Tartar emet., Tabacum, Secale cor. For the
DISEASES OF THE ORGANS OF DIGESTION.
745
hydrocephaloid condition which sometimes ensues, compare thusa,
Apis, Bryonia, Calcarea phos., Cuprum, Ferrum phos., Helleborus, Phos-
phorus, Podophyllum, Sulphur, Zincum.
OBSTRUCTION OF THE BOWELS.
BY J. G. GILCHRIST, M.D.
By obstruction of the bowels is understood a more or less perfect closure
of any portion of the intestinal canal, whether from traumatism or
from morbid action in the intestines themselves, or in near parts.
Systematic works on medicine and surgery usually give at considerable
length a résumé of numerous morbid processes which may result in
such a catastrophe, but it has seemed to me that much of it is in the
nature of mere repetition, and a simpler treatment of the subject would
be desirable. It is apparent that obstruction must occur from a few
general classes of causes; as, for instance, plastic exudation from in-
testinal morbid states, compression from abnormal growths outside of
the canal, the impaction of foreign material, or some accidental change
in relation of one part of the canal with another. With such an
arrangement, one that seems natural to me, I am of the opinion that
a practical classification would be to consider such obstructions to lie
in one of two classes as to causation and semeiology, acute and chronic,
the former being further subdivided into accidental and symptomatic.
ACUTE INTESTINAL OBSTRUCTION.
An individual, previously in good health, occasionally, perhaps,
with a history of more or less chronic intestinal irritation, is suddenly
taken with a sharp pain in the abdomen, one that does not pass off
speedily, but is persistent and progressive. There may be urging to
empty the bowels, more or less effectual at first, but later nothing can
be expelled. Enemas return almost or entirely unchanged, and yet
the urging continues. On examining the abdominal surface by palpa-
tion, it will feel fuller than usual, painful at one spot, or in a limited.
area, with more or less sensitiveness over the whole surface, but not
that peculiar painfulness indicative of peritonitis. The fulness gradu-
ally increases until there is tympanitis, soon becoming extreme, the
pain increasing pari passu with the augmented swelling, and gradually
becoming diffused, yet still with greater sensitiveness at one point, the
focus from which the later symptoms develop. There will be much
belching of wind, at first somewhat relieving the distension and pain;
hiccough then comes on and vomiting, which towards the last becomes
stercoraceous. The skin becomes dry, at first, later is clammy and
cold, the sweat having an offensive fæcal odor. The breath is likewise
746
A SYSTEM OF MEDICINE.
of fæcal odor; the face is pale, and the countenance denotes great dis-
tress and anxiety. The urine is often suppressed, although at times it
is increased in quantity and micturition frequent. The mind be-
comes increasingly disordered, until profound apathy, in some cases
even some delirium, is present. If the symptoms are not relieved and
the case is progressing towards a fatal termination, the fæcal odor of
the perspiration, exhalations and breath changes to a cadaverous or
gangrenous one, and the apathy becomes a coma. In some cases re-
covery ensues even when the above grave symptoms come on, but as
a rule, death is almost certain. In lighter cases, the symptoms being
the same in kind but less in degree, recovery is slowly assured; but
even in such instances the whole complexion of the case is one that
causes the observer much concern.
A comparison of the above with the symptoms of hernia shows a
remarkable similarity, and a study of the pathology does not lessen.
the resemblance. The conditions are almost, if not quite, identical,
there being a constriction of the intestine in some way, all the more
dangerous from the fact that the lesion is concealed, and can only be
recognized as a variety of a class of accidents.
Acute obstruction being pronounced, some external signs sometimes.
appear. If the abdomen is too sensitive to be properly explored, an
anæsthetic may be used, and almost invariably a "sausage-like " tumor
can be felt, which should be considered diagnostic. After the tym-
panitis becomes considerable, it is manifestly impossible to detect the
tumor through the walls of the abdomen. In such cases it may be felt
through the rectum or vagina. There are some points of interest as to
differential diagnosis, many of which, however, will need notice later.
The sudden onset of the attack resembles renal colic or peritonitis,
peri-typhlitis, or passage of gall-stone. The pain usually occurring in
the right inguinal region, acute obstruction oftener being at the lower
portion of the ileum, there are many reasons for mistaking the condi-
tion in the earlier stages. The tympanitis, localized pain, eructations
of gas, fæcal odor of the exhalations and vomiting, particularly when
stercoraceous, should serve to render a diagnosis reasonably clear,
more especially when the symptoms occur in a child.
Pathology. In my own practice I have seen eleven cases of acute
intestinal obstruction, and my case-book shows that eight of these oc-
curred in children under two years of age. One was in a woman of
about seventy, one in a man of thirty, and the other in a man about
twenty-five. The cases among children all recovered, without any
operation in seven of them; the cases occurring among adults all·
proved fatal. This seems to be the usual experience of the profession,
at least as to the question of age; in fact, I believe that cases occur-
ring in infancy, also, are less fatal than when later in life. As to
among adults I have seen one woman and two men, the children
sex,
DISEASES OF THE ORGANS OF DIGESTION.
747
were all female. The experience of others in this respect, so far as I
am able to conclude, is somewhat similar.
In the acute forms obstruction occurs from intussusception, volvu-
lus (or twisting), internal hernia, or intestinal paralysis from trau-
matic lesions. Taking together all forms, acute and chronic, Pollock,
according to Keetley (Index of Surg., p. 148), tabulates 135 cases, from
which it appears that "24 arose from intussusception, 36 from bands,
diverticula and the like, 33 from intrinsic stricture, 8 from internal
hernia, 7 from concretions, calculi and foreign bodies, 4 from volvulus
of sigmoid flexure, 3 from fæcal accumulations, 9 from peritoneal ad-
hesions, tubercle, etc., and 8 were doubtful." It thus appears that 51
cases were acute in character, assuming the "8 doubtful" to be with-
out apparent cause, and 84 chronic. This table might be quoted to
argue the preponderance of cases in the adult periods of life, as chronic
affections leading to stricture are more common among those who have
passed the age of childhood. I am willing to allow it to thus stand,
although my own experience and that of professional friends would
lead to a different conclusion.
Intussusception is a condition in which one part of the intestine is
drawn into a part below it, "telescoping," as it is otherwise called.
This may occur at any part of the intestinal canal, oftener, however,
at the lower portion of the ileum. The cause is usually a violent
peristaltic action, whereby a portion is slipped into a lower part of its
own body, so that at the point of invagination there are four thick-
nesses or layers of intestinal tissue. If the peristalsis is continued,
the invagination may be increased until the ileum is drawn into the
colon, which last may also become inverted from the irritation con-
sequent upon its unwonted contents, until the ileo-cæcal opening may
present at the anus. I have seen one such case, a patient of Dr. R. C.
Olin, of Detroit, an infant a year, or so, of age. In this there was some
sloughing of the constricted portions, and a perfect recovery; in fact,
the child was better in health than it had been from its birth, a habit-
ual constipation having disappeared. Intussusception may likewise
occur from the traction of tumors growing in connection with the in-
testine, more particularly, as in the case of the rectum, when a polypus.
grows from the mucous surface. Accumulations of fæces, or foreign
bodies of various kinds, may likewise be causative. Under such cir-
cumstances invagination may occur at any point, but the chosen seat
is at the lower end of the ileum, in these cases as well, from the nature
of the part predisposing to the arrest of foreign material and the forma-
tion of tumors.
The natural history of intussusception shows that the tendency is to
take on inflammatory action, contract adhesions, the constricted por-
tion then sloughing off, to be discharged per anum. Cases are on
record of large masses of intestine coming away in this manner; in
748
A SYSTEM OF MEDICINE.
(6
one case some feet of the ileum, together with the cæcum and five
inches of the colon, came away in a stool, and the patient recovered.
(Trans. Califor. Hom. Med. Soc.) Gant (Science of Surgery, p. 980) gives
the results in "24 cases of intussusception, occurring at various periods
of life, from two months and a half to fifty years of age,” as follows:
'13 of the patients died unrelieved, some as early as three days, some
as late as forty days, from the commencement of the symptoms. But
in the other 11 cases the invaginated pieces of intestine sloughed and
were passed by stool. Of these cases, only 2 died soon after the pas-
sage of the slough; the remaining 9 entirely recovered. The patients
who recovered were ill for periods varying from five to thirty days,
and their ages ranged from six to fifty years." In my own cases the
adults perished in from one to four days; in the cases among children
sloughing occurred in seven, and one recovered without any appear-
ance of a slough.
Volvulus, or twisting of the intestine, seems to occur next in frequency
to intussusception. It is more commonly met with in the colon, par-
ticularly in the sigmoid flexure. This form of obstruction is produced
in three ways: In the first, the bowel is twisted or rotated on its own
axis, sometimes more than one turn being made. This form is pecu-
liar to the colon, in fact, cannot well be produced in any other part of
the canal. It is caused, in a majority of cases, by such injuries as
being whirled around in machinery; it can scarcely occur from causes
operating within the body, although it has been said to be the result
of the traction of tumors, particularly when pendulous. In the second
variety the mesentery becomes twisted, twisting loops of small intes-
tines with it. This is likewise produced by accidents that violently
rotate the body. The third method is when one portion of intestine
is twisted around another. As far as results are concerned, they are
about the same in these cases of volvulus as in intussusception. In-
flammation occurs, adhesions are formed, the parts involved become
strangulated, producing death or sloughing.
Internal hernia is a form of obstruction which is thought to be quite
common. It is produced by forces causative of hernia generally, viz.,
a violent contraction of the abdominal walls, reducing the capacity
of the cavity. The peritoneum or mesentery is ruptured, and a por-
tion or knuckle of the intestines is forced through the opening, be-
coming strangulated. The rupture of the peritoneum is accompanied
with great pain, and the resulting peritonitis, added to the intestinal
obstruction, produces symptoms of the greatest urgency. This form
of obstruction is more rapidly and surely fatal than either of the pre-
ceding; in fact, recovery is almost an impossibility. Strangulation to
a degree which causes obstruction (and any constriction sufficient to
retain the intestine in the opening in the peritoneum will cause this)
must be followed by sloughing. Sloughing, under these circumstances,
DISEASES OF THE ORGANS OF DIGESTION.
749
almost inevitably destroys life, even if the patient survive long enough
to give time for detachment of the dead tissue. A slough being thrown
off is usually retained within the abdomen, external to the peritoneum,
not only as a foreign body, but a decomposing one-thus adding vastly
to the violence of the peritonitis. Furthermore, and perhaps of the
first importance, this separation of dead tissue does not restore the
patency of the intestinal canal. The two extremities are either re-
tained in the peritoneal opening, or, should they drop back after the
detachment of the slough, the contents of the bowel are discharged
into the peritoneum, rendering more dangerous a state that is already
well-nigh hopeless.
Intestinal paralysis is spoken of by some authors as an occurrence
somewhat frequently following certain spinal lesions, but the records
are not sufficiently authentic to base upon them any theory. Paralysis
might very easily permit volvulus, if the intestines were held in posi-
tion by a contracting force, such as muscular effort. As a matter of
fact, they are purely in a state of suspension, and paralysis could not,
as far as I am able to see, have any result or influence in producing
obstruction. From what I have read in some of the larger systematic
works on surgery I am led to believe that those who thus speak of
paralysis as a causative factor have misinterpreted their authorities.
It seems evident to me that paralysis of the intestines is productive of
retention of fæces, which causes obstruction by blocking them up, and
should thus be classed in the chronic group. The loss of peristalsis
can only, it would seem, cause obstruction in this way.
A glance at the various causes producing intestinal obstruction
readily shows that, after traumatism, peristaltic action is oftener promi-
nently concerned. There are many minor accidental factors, not
mentioned in the above category. Thus, purgative medicine, severe
diarrhoea or dysentery, and, under some circumstances, constipation
would greatly increase the peristaltic action, and predispose to intus-
susception. An accumulation of hardened fæces, as in the sigmoid
flexure, would favor the production of volvulus, and so on through
a long list.
Foreign bodies in the intestinal canal may produce obstruction in two
ways. Their bulk may constitute a perfect and complete obstruction.
Their presence may excite a muscular irritability that results in a
spasmodic stricture. Foreign material does not always, or necessarily,
come from without the body; excrementitious material, produced
within the body, if retained beyond a reasonable period in the canal,
becomes foreign, to all intents and purposes. More than this, it may
be, and is, the most dangerous of any form of purely mechanical oc-
clusion, as, joined to the dangers associated with all kinds alike, we
have an obstructing element here of putrefiable material, whereby
septicemia, or some other form of toxæmia, may be produced. Whilst
750
A SYSTEM OF MEDICINE.
a foreign body, introduced from without the body, may be insoluble,
and of a size to at once prevent the passage of the contents of the
bowel, yet it has no toxic characters, and is, perhaps, more readily
removed.
The termination of these latter forms of obstruction, impaction of
foreign material, is often in ulceration and sloughing of the intestinal
walls in relation with them and the passage of the offending body
into the abdominal or pelvic cavity. In some cases adhesions have
occurred between the intestine and the abdominal walls, and the for-
eign substance is cast out by suppuration. When it escapes into the
abdominal or peritoneal cavity, inflammation and suppuration are
necessarily the consequence.
Prognosis.-Gant's summary shows a mortality of 15 out of 24, a
fact that leads me to infer that death resulted from conditions secon-
dary upon the intestinal obstruction. He tells us that "13 of the
patients died unrelieved," a little more than half. Two others died
after the constricted intestine had been cast off. In my own list of
11 cases the recoveries were 8, almost reversing Mr. Gant's conclu-
sions. It is perfectly natural to attribute this better showing to the
aid furnished by homoeopathic therapeutics; it is not impossible, how-
ever, that there were differences in the cases more than sufficient to
account for the differences in results. I am the more inclined to be-
lieve this to be the case for two reasons: first, the records generally
bear testimony to the exceedingly fatal character of the accident; and
secondly, there is little for remedies to accomplish. At the same time,
recovery sometimes occurs under circumstances that would forbid,
apparently, any hope of a cure. It may be stated that when slough-
ing of the constricted portion occurs, and it is discharged from the
body, the prognosis is usually good. When sloughing occurs and the
dead tissue is left within the body, the prognosis is correspondingly
bad. One case which I saw had inversion of the colon to an extent that
permitted the ileo-cæcal opening to appear at the anus, and yet re-
covery was secured. No reason could be assigned for the favorable
result, certainly there were no indications for remedies. The strangu-
lated portion of the ileum sloughed, and even an improvement in the
former health was observed.
Treatment.-Intestinal obstructions of all kinds, but particularly
those of the acute variety, lie eminently within the domain of surgery.
The only means of relief that are at all certain are formidable surgical
operations, more particularly laparotomy and excision, or whatever
may be required, of the obstructed bowel. In studying the natural
history of the accident, more particularly its pathology, it must be
at once apparent that remedies can have very little influence in the
pronounced forms. With intussusception of a minor degree, coming
on as a complication of diarrhoea or dysentery, it is possible, nay,
DISEASES OF THE ORGANS OF DIGESTION.
751
probable, that remedies, by moderating the violence of the unusual
peristaltic excitement, may relieve the constriction. But when the
constriction is severe, or a considerable portion of intestine is involved,
the plastic adhesions induced by the inflammation forbid any hope
of reposition unaided by mechanical means. The only hope of a con-
tinuance of life is in the early sloughing of the constricted portion or
in its release by a surgical operation. I presume there is little ques-
tion that many cases of a minor degree of constriction have been un-
wittingly cured. Probably many a case has been diagnosticated as
"bilious," or some other kind of, colic, and Colocynth., Stannum, Bella-
donna, Nux vomica, or Podophyllum, have relieved all the symptoms.
At an early stage it is difficult, if not absolutely impossible, to make
a diagnosis, and remedies given on ordinary indications may have
produced cures, curing a condition unrecognized by the prescriber.
Later in the case, with the pathognomonic symptoms plainly pictured,
I do not know how or in what manner remedies can possible exert
any influence. I have seen them employed, more than once, by the
very best prescribers, and invariably without result. To illustrate, I
made a post-mortem examination, in 1864, for Dr. H. N. Guernsey, a
man who has a large reputation as a skilled prescriber. Even his excep-
tional skill was powerless to save the life or to relieve the sufferings of
his patient, a young man, who had been in previous good health and
vigor. I am forced to refer to works on surgery, therefore, for details of
the treatment of acute intestinal obstruction, admitting, at the same
time, that the minor degrees or recent cases may possibly be relieved,
if not cured. The remedies that would seem to have the closest relation
to the condition, in addition to those mentioned above, would be such as
give violent peristaltic action, as drastic purgatives, particularly whose
subjectivity includes violent and localized abdominal pains. These
are, among others, Aloes, Arsenicum, Croton tig., Palladium, Plumbum,
Platinum, Cuprum acet., Veratrum album, perhaps Chamomilla, and other
remedies more exceptionally useful in colic. The generation of free
gas in the intestines, what Dr. Danforth, of Milwaukee, calls the "soda
fountain" treatment, has been successfully employed once or twice.
While such treatment will probably be very successful in recent cases,
where there are either no adhesions or the constricting force is feeble,
in cases of a different sort, where adhesions are firm and many,
and
where the constriction is severe, there is danger of rupturing the intes-
tines, and thus converting a case perhaps capable of recovery, into an
utterly hopeless and irremediable one. Pumping air into the rectum
has always enjoyed a reputation which appears undeserved; still, as
compared to free gas, it is a perfectly harmless procedure, and might
succeed in a mild case. Cases have been relieved by passing a long
rubber tube up the rectum and through the colon, and injecting fluids
or air through it when the point of stricture is reached. When air or
752
A SYSTEM OF MEDICINE.
gas is used, success is announced by the rush of the gas out of the
mouth, as well as the sudden subsidence of pain. The pain does not
cease at once upon the removal of constriction, the bruised and in-
flamed parts remaining painful for some time, and sensitive to pres-
sure still longer. Notwithstanding the negative results of remedies,
at least as indicated in our most authentic records, the physician
should not neglect their employment; they may possibly, I repeat, be
of service in cases of a minor degree of severity. Reliance must never
be had on them alone; such expedients as have been hinted at above
must be employed. As soon, however, as it becomes very apparent
that relief is not to be attained by any of these measures, the aid of
the surgeon must be called. This aid must not be postponed too long.
Remembering that the fatal cases are those in which surgical measures
have been delayed until the patient was almost in articulo mortis, and
that "nature's cure," sloughing, does not invariably avert death, the
surgeon should see such cases early. If gastrotomy is to be performed,
it is successful when made while constitutional disturbance is small
and insignificant. Peritonitis, extensive gangrene, and the like, very
greatly jeopardize the success of an operation.
The common indications of remedies which seem to have a relation
to acute intestinal obstruction, are as follows:
Aloes.-In elderly people, with intense griping pains across the lower part of the
abdomen, oftener on the right side; flatulent, watery stools.
Arsenicum.-Violent cutting, or spasmodic, drawing, tearing or gnawing pains,
frequently attended with intolerable burning, or with feeling of coldness in the abdo-
men; thirst (for small quantities) and great weakness.
Belladonna.-Colic as if a spot in the abdomen were seized with the nails;
griping; clutching, or clawing; pains come and go suddenly; tenderness to slight
pressure, but relief from strong pressure.
Chamomilla.-Sensation as if the bowels were drawn up into a ball; griping,
tearing colic in the umbilical region, and lower down on both sides, with pain in the
small of the back as if it were broken. Hard pressure on the painful point relieves.
(Bell., relief from pressure over the abdomen generally, a diffused pressure.)
Colocynthis.-Violent cutting and tearing colic, as if cut with knives; pain
intense, obliging one to bend double. The pain radiates from a central point, and is
renewed or aggravated by every motion; relieved by hard, firm pressure on the centre
of pain.
Croton tigl.-Colic, with sudden, profuse, and watery stools; "stools come out
like a shot."
Cuprum acet.-Abdomen is drawn in, with violent cutting or drawing pains;
unchanged by pressure; spasmodic contractions of the abdominal muscles.
Nux vomica.-Colic, with violent pains in the small of the back; soreness and
lameness of the abdominal muscles on motion or on touching. Stercoraceous vom-
iting and singultus, signifying strangulated hernia, and commonly supposed to indi-
cate this remedy.
Palladium.-Violent colic, more on the right side, growing worse under con-
tinuous eructations; can only endure the pain when lying on the left side; cramps in
the extremities, and somewhat relieved from moist heat.
Podophyllum.-Cramping pain, with retraction of the abdominal muscles;
stools profuse and very offensive, dark color.
Platina.—Continuous, severe, contracting pain, chiefly in umbilical region, ex-
tending through to the back.
DISEASES OF THE ORGANS OF DIGESTION.
753
Plumbum.-Severe, contracting pain, the muscles being drawn in; clawing and
twisting pains about the umbilicus, radiating upwards and downwards.
Stannum.-Pinching colic, with tonic spasms of the muscles, obliging to bend
double, or press the part against a hard substance, as a chair or corner of a table.
Veratrum alb.-Abdomen swollen, sensitive, cold sweat, and general cold-
ness; cold feeling in the abdomen; cold breath; cramping, twisting or cutting pains.
CHRONIC INTESTINAL OBSTRUCTION.
Chronic obstructions of the intestines include morbid processes that
are slow and progressive in their action, and while the later symptoms,
those of complete occlusion, are the same as in the case of acute ob-
structions, yet the prodromal and earlier symptoms are very different.
These early symptoms vary greatly, as a matter of course, having more
relation to the morbid action, of which they are an expression, than to
the condition of the intestines themselves. Some brief notice of these
conditions will, therefore, be necessary. They may be grouped under
the following heads: Strangulation by bands or diverticula, congeni-
tal or acquired; Strictures of various forms; Pressure or dragging
from tumors; Impaction of fæces, or slowly accumulating foreign
material.
Symptomatology.-The symptoms of various forms of morbid
action which result in obstruction of the bowels, are those peculiar to
the particular form of morbid action; it is very rarely the case that
those of intestinal obstruction appear at the same time that other
symptoms do. It is impossible, therefore, to treat of these prodromal
symptoms, as they may be called, at this time, inasmuch as it would
involve a more or less lengthy description of much that has already
been considered in other portions of this work. When the morbid ac-
tion has progressed sufficiently to affect the intestines injuriously, to
diminish their calibre, and to alter their walls or tunics, other symptoms
arise, generally obscure in their nature, and varying somewhat with the
part of the canal implicated. Thus, with the morbid action operative
in the duodenum or jejunum, or in the upper part of the ileum, there
would be primarily diarrhoea, perhaps vomiting, or some other indi-
cation of gastric irritability. Should the vomiting occur after a time
sufficient to allow the food to pass into the intestines, some idea of the
locality of the lesion can be formed. When it occurs earlier, as is very
often the case, there is much difficulty in determining whether the
lesion is in the stomach or lower down, the presumptive evidence
pointing to the stomach. The stools, when diarrhoea occurs, usually
present some evidence of value. The appearance of mucus, pus, blood,
or shreds of membrane, would indicate a lesion of the cæcum or colon.
If examination excludes the colon, the lesion is located in the small
intestine. Should there be cellular elements, pathognomonie in kind,
the character of the lesion can be made out as well. When the con-
striction has become considerable, there will be very often an accumu-
VOL. I.-48
754
A SYSTEM OF MEDICINE.
lation of gas interior to the stricture, and quite frequently a lodgement
of a portion of the contents of the bowels, which may gradually assume
the form and other characters of a tumor. The constriction finally
becoming pronounced, the difficulty with which the ingesta pass that
point will quite often establish a diagnosis. The violence of the per-
istaltic action consequent upon this obstruction, the accumulation of
gas and other material at the point of constriction, give rise to peculiar
symptoms, the so-called "phantom-tumor," which ignorant people
mistake very often for a live animal that has found its way into the
body. I have seen one very ludicrous mistake of this nature, in which
a physician was with the greatest difficulty restrained from opening
the abdomen to secure this intruder, desiring to exhibit it as a curiosity
in a museum. When obstruction becomes complete (if it should do
so during the life of the sufferer), the accumulations interior to it, the
absence of any fæcal substances in the discharges from the bowels,
and the vomiting of stercoraceous matter, combine to render a diagno-
sis comparatively easy. In later stages of the disease there is much
emaciation and prostration, suppression or diminution of the urinary
excretion, and every indication of profound lowering of vital energy.
With all this will be mixed up the symptoms of the form of morbid
action responsible for the obstruction, and which does not now concern
us.
The seat being in the colon, the symptoms are somewhat different.
The changes in the stools here are in the direction of constipation, or,
should there be diarrhoea, it is dysenteric. Later in the case, however,
as far as proper fæcal matter is concerned, there is positive constipa-
tion, retention of stool. There may be much urging to stool, and a pas-
sage from the rectum of mucus more or less bloody or purulent, but there
are no fæcal movements whatever. The colon becomes increasingly dis-
tended with the accumulated dejecta, and when emaciation is consid-
erable, which soon becomes the case, it can be felt as a hard, sausage-
like mass throughout its extent. The fulness will first be observed
immediately interior to the point of obstruction, and extend from this
point, in daily accessions of size from left to right, and, on the right
side, from above downwards. The exhalations and breath then have an
offensive fæcal odor, the tongue becomes furred, sordes may accumu-
late on the teeth, tongue and lips, the tongue becomes dry and parch-
ment-like, the eyes dull and lifeless, the mind impaired, and all the
bodily functions become more and more disordered.
In chronic obstructions, whether in the large or small intestines,
there is little pain arising from the condition of the bowels; what pain
there is, is associated entirely with the causative morbid action. Even
late in the case, when the bowel is completely occluded, pain is neither
constant nor severe. This is accounted for, to some extent, from the
gradual progress of the distension, the parts having opportunity to
DISEASES OF THE ORGANS OF DIGESTION.
755
accustom themselves to the new relation of things, and from the loss
of sensitiveness due to distension. Even the natural feeling of fulness,
which is often distressing, gives way, after a time, and as the fluid
portions become absorbed, or otherwise disposed of, the distension is
partly relieved. The pain which occurs is temporary and fugitive,
caused by accumulations of gas.
Apart from the symptoms connected with morbid conditions at the
bottom of the trouble, the case is of a character to baffle the skill of
the most expert diagnostician. When the stools become deficient, day
by day more and more scanty, attention is directed to the bowels; soon
after, however, the distension of the parts interior to the constriction,
and other symptoms noted above, become so marked and prominent
that it is difficult to err.
Pathology. As was the case with acute intestinal obstruction,
a discussion of the pathology includes rather more ætiology than
pathology pure and simple. This is not because the pathological
states are not marked and characteristic, but because the lesions giving
rise to the obstruction is the point of chief interest, and these have
already been considered in their proper place. Taking the list of va-
rieties already given as typically representative of the innumerable
causes, I will very briefly allude to them in the order of their pre-
sumed frequency.
Bands or diverticula often cause obstruction. These may be acci-
dental or acquired. They are accidental when plastic organization re-
sults from inflammation, either of the bowel or near parts. They also
occur from injuries followed by cicatrization. They are congenital,
usually in the form of diverticula, from malformation, or arrest of
development. It is possible, as some have asserted, that injuries sus-
tained in utero may produce obstruction. In the majority of congeni-
tal cases the obstruction seems to be either in an unusual flexure of
some part of the intestinal tract or in a termination of the bowel in
a cul-de-sac. In other cases there is no opening into the colon, the
ileum terminating impervious.
Stricture is a very common cause of obstruction. Perhaps a purely
spasmodic closure is rare, apart from the impaction of a foreign body,
and yet there seems to be good evidence that it is possible. A foreign
body remaining for some time impacted will be the cause of sufficient
irritation to produce a sensible constriction from purely muscular
contraction. To be sure, the swelling and engorgement of the mu-
cous membrane will have the effect to make the stricture appear more
pronounced. Should the constriction continue for any time, however,
there will be exudation and more or less plastic organization, which
may perpetuate the obstruction. More particularly is this the case
should there be any erosion of the mucous surfaces or ulceration, or
any kind of lesion that would be healed by cicatrization. It is thus
756
A SYSTEM OF MEDICINE.
apparent that while a purely spasmodic stricture, if unassociated with
a structural lesion, should not necessarily leave any organic constric-
tion behind it, yet if from any cause there has been plastic exudation,
a permanent impairment of structure will follow. Cicatrices from
wounds or ulceration, from the well-known contracting properties of
scars, are exceedingly liable to produce strictures of more or less.
tightness. This is eminently true of carcinomatous ulcerations. A
slight stricture, non-malignant, may induce obstruction by what is
called "Pouching" of the intestine. A stricture which extends deeper
than the mucous coat, one which involves the submucous tissue or the
muscular layers, must be a serious impediment to the passage of the
contents of the bowel from the loss of peristaltic power. In such a
case there is a danger of a portion of the substances passing through
the bowel becoming arrested on the proximal side of the stricture, and
forming the nucleus for a collection that may become enormous. The
intestine at this point will gradually become distended, sacculated,
and by traction expose the gut to danger of volvulus, or close it by
the traction alone.
Tumors of all kinds, growing outside of the intestinal tract, may
close the canal by pressure exerted directly thereon. If carcinoma-
tous, they invade the tissues, as already described in another place.
If attached to the internal surface, particularly if pendulous, they
close the canal by their volume, or by traction produce intussuscep-
tion. When growing from the subserous side, they predispose to vol-
vulus, and also to closure of the tube by mere traction.
Impaction of fæces or other slowly accumulating foreign material
occurs, for the most part, at the sigmoid flexure, the ileo-cæcal opening,
or at some part of the canal where a sharp turn is made, or some nar-
rowing of the tube occurs. Even should the accumulation not be
sufficient to fill the intestine, pouching may occur, and volvulus or ob-
struction by traction. When the foreign material is hard, or becomes
so by the removal of the watery or fluid portions, there is additional
danger of erosion of the mucous coat, ulceration, gangrene, or rupture
of the intestine.
The above may be esteemed as a fairly typical classification of causa-
tion and pathology. As a matter of course, a minute classification
would include many conditions not noted; and yet there can scarcely
be a case of chronic obstruction of the bowels that will not fall natu-
rally into one or the other of these classes.
Prognosis.-Prognosis is uniformly bad, more particularly when
the cause lies in some kind of morbid action. When accumulations
of fæces or other foreign material can be made out early in a case, life
may be preserved; so also with constriction from cicatricial contrac-
tion. Unfortunately, however, an early diagnosis is next to an impos-
sibility, save in very exceptional instances. This fact alone would
DISEASES OF THE ORGANS OF DIGESTION.
757
make the prognosis very unfavorable, but even with the facts reversed,
the condition would be very little changed for the better.
Treatment.-If acute intestinal obstruction falls within the do-
main of surgery, of which there can be no question, certainly it is
eminently true of the chronic form. No matter what the lesion may
be which antedates the stricture or obstruction, once produced, it is a
case for the surgeon alone. If a cure can be secured at all, it must be
through an operation of some kind, often one of the most formidable
character. The only instance in which medicine may be supposed to
have any value would be a cicatricial stricture resulting from ulcerá-
tion or injury. Here Silicea, given on general principles, may exert a
beneficial influence from its property to loosen up cicatricial adhe-
sions and to metamorphose scar-tissue. Given on these indications,
immediately after the cure of an ulceration, it is possible to avert subse-
quent contraction. Later in the case, when the stricture has been de-
veloped, and there is considerable dilatation of the gut interior thereto,
Silicea must be counted out of the problem.
As far as the physican is concerned, his indications are plain, but,
alas! not as easily fulfilled. Thus, if there is foreign material impacted
at any point, it must be removed. If morbid action is the cause, it
must be attacked. The morbid action being carcinoma, the case may
be considered hopeless. When the obstruction has become pronounced,
and assumes the first place in the case, the surgeon must be employed.
Laparotomy must be made, the constriction found, and if possible re-
moved. The means to be employed for this purpose are outside of
our present inquiry, and the reader must go to the works on surgery.
HERNIA INTESTINALIS.
BY J. G. GILCHRIST, M.D.
The term hernia is used to indicate a protrusion of viscera from any
of the great cavities of the body, whether through natural outlets, as
the canals for the passage of vessels, or accidental openings. By com-
mon consent, in modern times the term, unqualified by some prefix,
refers particularly to protrusions of abdominal viscera, more especially
the intestines or omentum. In the present place, in view of the fact
that the condition is almost entirely of surgical interest, it will not
be attempted to present an exhaustive treatise on either pathology or
therapeutics, more particularly the latter, inasmuch as the vast ma-
jority of cases demand mechanical or operative treatment, whether for
cure or palliation. The subject is one that has always engaged the
interest of medical practitioners, and the literature is exceedingly
voluminous. Much of this literature is burdened with obsolete and
758
A SYSTEM OF MEDICINE.
barbarous terms, terms that are only used to-day in systematic
treatises, it appears, more for the purpose of showing the writer's
familiarity with this literature than for any useful purpose. Sim-
plicity, as to classification at least, will, therefore, be sought in the
present instance, and many of these time-honored terms will be
ignored.
Abdominal or intestinal hernia may be described as a tumor sud-
denly appearing at some part of the abdominal parietes, or near
neighborhood, or one existing from birth, soft and more or less com-
pressible, globular or pyriform in shape.
In studying these protrusions it is essential, both as a matter of
diagnosis and for therapeutical purposes, that some rational form of
classification should be adopted. Herniæ, accordingly, are classified
first with reference to location; second, to contents of the tumor; third,
to duration; and fourth, as to reducibility.
Location.—A hernia protruding through the inguinal ring is known
as inguinal hernia, and may be direct, oblique, or straight. It is oblique
when the viscera enter the internal abdominal ring, pass along the
inguinal canal, in company with the spermatic cord in men (or the
round ligament in women), and emerges through the external ring.
It may descend in the one case into the scrotum, being then known
as scrotal hernia, or, in the other case, into the labia majora, then called
pudendal hernia.
Inguinal hernia is direct when the protrusion occurs through the
external abdominal ring at any point internal to the epigastric artery;
in other words, when the intervening tissues are pushed before the
viscera, and do not enter at the internal ring, thus not occupying the
inguinal canal.
Straight inguinal hernia exists when from long standing of the malady
the internal ring is dragged down opposite the external, thus obliterat-
ing the canal and forming a direct opening into the abdominal cavity.
The significance of these varying conditions lies in the following:
Indirect or oblique hernia is likely to be of recent or non-traumatic
origin, or the result of some congenital or hereditary defect. It is,
therefore, more likely to yield to mild methods of treatment. When
it is direct, on the other hand, it is nearly always traumatic, and implies
such a change in the relation of the parts involved that some radical
surgical measures are likely to be demanded for its relief. A straight
hernia is always an old one, and represents a condition of the mes-
entery which forbids all hope of a retention of the mass within the
abdomen, and the indications for treatment are, therefore, largely for
palliation.
Should the tumor appear below Poupart's ligament, it is in relation
with the femoral or crural canal, and is known as femoral hernia.
When through the ischiatic notch, it becomes ischiatic hernia. At the
DISEASES OF THE ORGANS OF DIGESTION.
759
umbilicus it is umbilical hernia. And when it appears directly through
the abdominal walls, not through a natural or existing outlet, it is
spoken of as ventral.
The same significance attaches to this classification as in the case
of the inguinal varieties. Thus an umbilical hernia is usually con-
genital, and represents a structural defect in the parts involved. A
femoral hernia is practically of the same character as the oblique in-
guinal, being oftener found in women, however, as the inguinal canal
is less likely to remain patent with women than men. Ischiatic hernia
is to be considered of the same class, as there is a natural opening.
Ventral hernia, on the contrary, is always a result of traumatism.
Contents.-The second classification refers to the contents of the
hernial protrusion, and is particularly useful as furnishing data for
prognosis as well as therapeutics. Should the contents be entirely
intestines, it is called an enterocele; if omentum, epiplocele; should
both intestine and omentum be present, the term entero-epiplocele is
used. As to prognosis, life is less immediately threatened in cases of
epiplocele than when the intestines are involved. As to curative
measures it may, in exceptional cases, be proper to remove an ob-
stinate epiplocele, a procedure that could rarely be justified in cases
of enterocele. As to the differential diagnosis, it may be noted in
passing that when a hernia can be reduced, if the act is accomplished
with a gurgling sound, it is likely to be enterocele; if with a sucking
sound, epiplocele. The sounds in cases of entero-epiplocele are rarely
diagnostic.
Duration. Thirdly, hernia is classified with reference to its dura-
tion. When recently produced, it is called recent or acute, and repre-
sents often a condition of traumatism, with good promise of curability.
When of long standing, it is known as ancient or chronic, and represents
a condition of the parts in which long traction, or other causes, has
more or less permanently placed the condition beyond the hope of
curability. Furthermore, an ancient hernia is either congenital or
acquired. In the former case we may expect to find a structural
deficiency that may prove irremediable; in the latter, the parts may
be altered by the long standing of the hernia, but not necessarily of a
kind or degree of alteration that forbids more or less perfect restora-
tion.
Reducibility.-Lastly, hernia is classified with reference to the
ease with which it may be reduced, or its practicability. When the
mass is readily returned within the abdomen, it is spoken of as
reducible. When such reduction is impossible or difficult, it is called
irreducible, or partly so. Irreducibility may be due to the existence
of adhesions and may be absolute, when the term incarcerated is to be
preferred. It may, again, be of an acute character, either from infla-
tion of the prolapsed bowel with air, or distension from fæces, or the
760
A SYSTEM OF MEDICINE.
contraction of the tissues surrounding it, when the term strangulated is
used.
This classification may be arranged schematically as follows:
Direct.
1. Location.-Inguinal Oblique {
Straight.
Scrotal.
Pudendal.
Femoral.
Ischiatic.
Umbilical.
Ventral.
2. Contents.-Epiplocele.
Enterocele.
Entero-epiplocele.
3. Duration.-Recent, or acute.
Ancient, or chronic
Congenital.
Acquired.
4. Reducibility.-Reducible.
Irreducible {Strangulated.
S Incarcerated.
Semeiology. Before studying the pathology of hernia, it is neces-
sary that the symptoms should be described. It will be a natural
arrangement to consider incarceration or strangulation the usual ter-
mination of a hernia, as is to some extent the case. For convenience
of description, also, I shall consider the symptoms under two heads,
the reducible and irreducible forms.
Reducible Hernia.-It must be laid down as a truism that, under
all circumstances, the existence of a hernia is a constant menace to
the life of the individual. Even an old hernia, readily reducible, may
easily become strangulated, and the sufferer be placed in imminent
danger of death. So plainly is this indicated that applicants for
enlistment in either the army or the navy are rejected at once if they
are subjects of the smallest hernia, reducible or otherwise. Hence the
student must not fail to realize the exceeding gravity of this accident,
and the practitioner is bound to use his best efforts to secure a repair
of the injury. While certain symptoms are common to all forms of
hernia, yet it is not impossible to be led into a diagnostic error, under
favorable circumstances. In recent cases, perhaps, there is little dan-
ger of this if the history of the case is carefully scanned; but in
chronic cases, particularly when incarcerated, it often requires very
careful study to arrive at a proper understanding of the case. I shall,
therefore, subdivide our subject and consider the acute and chronic
varieties separately.
(a) Acute reducible hernia usually presents the following history:
DISEASES OF THE ORGANS OF DIGESTION.
761
An individual presents himself with a more or less painful tumor in
the groin or elsewhere, that has come on suddenly after some sudden
or unusual muscular effort. There was no swelling in the region
antecedent to the accident, and no history of inflammation or other
morbid action. The tumor is usually quite regular in form, more or
less globular, quite elastic, and is in a locality that would suggest her-
nia, as the supra-pubic or crural triangle. On lying down and main-
taining the recumbent posture, the tumor will diminish in size, per-
haps disappear. On resuming the erect posture it will reappear, or
become larger. On straining, as at stool, the size will often become.
greatly augmented. Grasping the tumor with the hand, and directing
the patient to cough, will, in the case of enterocele, communicate an
impulse to the hand of the examiner. Finally, on making pressure
on the tumor, in the direction of the canal with which it is in appa-
rent relation, should it disappear, and evidently through the canal, a
diagnosis may be considered as established. In the case of men, par-
ticularly young men, the scrotum should be examined for the testicle
on that side. In one case I found a truss worn to keep up a testicle
that had been delayed in its descent, under the supposition that it
was a hernia. In acute cases there is usually increasing pain as long
as the hernia remains unreduced, with a feeling of tension or dragging.
All these symptoms should disappear in reduction of the hernia. It
is dangerous, also, to permit a hernia to remain long unreduced, as
the protruded intestine may become distended until it cannot be
returned, and strangulation or incarceration result.
(b) Chronic reducible hernia will usually give somewhat different
symptoms, and the history will sometimes be necessary to make out
a perfectly satisfactory diagnosis. In the large majority of cases, how-
ever, the symptoms are unique and pronounced. Patients suffering
with chronic reducible hernia usually protect themselves by a truss,
and it is only occasionally and by accident that protrusion occurs.
Subjectively, there is a feeling of weakness or insecurity about the
parts, about the inguinal or femoral ring, as the case may be, and the
individual is often prompted to wear a truss as a precautionary mea-
sure. When, from any reason, protrusion occurs, the symptoms are
similar to those of acute or recent cases, with the exception of pain;
as a rule, such people are sufficiently familiar with the accident to
reduce it themselves. It is, consequently, an unfrequent occurrence
that a surgeon is called in on such occasions. But should the truss
become ineffective, medical advice is sought to produce a radical cure, if
possible. So, also, in cases of strangulation. When one testicle is ab-
sent, there is a coexistent hydrocele, or varicocele, or some other morbid
or abnormal condition of the parts, and a diagnosis may be difficult;
in fact, it can often only be reached by a prolonged examination
under an anesthetic, and a careful study of the history. Thus a his-
762
A SYSTEM OF MEDICINE.
tory of former hernia which was supposed to give place to some other
morbid condition, would lead to a suspicion of its continuance, more
particularly should the inguinal or femoral opening be unusually
large or patent, and should there be a noticeable increase in the pro-
trusion while standing, and a diminution while lying. The long-con-
tinued use of a truss very considerably alters the appearance of the
parts; usually the integument becomes thickened and somewhat dis-
colored; the interference with the venous circulation, particularly in
cases of inguinal hernia, causes stasis, and varicocele is a common
result. Other local changes may occur which, in progress of time,
assume such prominence that it may become anything but an easy
matter to settle the question of hernia. As a rule, however, the varia-
tions in size and the feasibility of reduction, particularly the reduction
occurring in the direction or axis of one of the common hernial canals,
remove much of the difficulty.
Sarcocele, hydrocele, hæmatocele, and varicocele may be mistaken
for hernia, or, existing in connection therewith, may complicate a
diagnosis. I will endeavor to give the differential diagnosis in a com-
parative table:
DISEASES OF THE ORGANS OF DIGESTION.
763
HYDROCELE.
VARICOCELE.
SARCOCELE.
HEMATOCELE,
HERNIA.
Pyriform shape.
Constant size.
Transmitted light shows
nature.
Narrow neck, or ceasing
before reaching the ring.
No "cough impulse."
Tumor is light in weight.
Bowels natural.
Elastic or fluctuating feel.
Gradual development, from
bottom upwards.
Compression does not dis-
perse the tumor.
Narrow neck, layer be-
low.
Ovoid or globular.
Constant size, or growing. Constant size, or diminish-
Pyriform or irregular.
Larger on feet, smaller on
lying down.
Opaque.
Thick pedicle at ring.
Irregular shape.
Ovoid shape.
Usually constant size.
ing.
Not translucent.
Opaque.
Opaque.
No pedicle, but cord may
be thickened.
No pedicle.
No "cough impulse."
Heavy.
No "cough impulse."
Heavy.
"Cough impulse."
Light, but heavier than
hydrocele.
Bowels natural.
Bowels natural.
Bowels constipated?
Firm feel, solid.
Elastic feel.
or
No "cough impulse."
Heavier.
Bowels as usual.
Doughy,compressible, may
be partly reduced in size.
Slow development, from
bottom upwards.
Compression may slowly
diminish size.
Fluctuates on surface, deep
pressure resisting,
boggy.
Slow growth, all parts Sudden appearance, trau-
Sudden appearance, trau- Rapid development.
simultaneously.
matic history.
Compression has no re-
sult.
Compression has no result,
or may break up clot.
Compression reduces tumor
through a hernial canal.
764
A SYSTEM OF MEDICINE.
Irreducible Hernia.-Irreducible hernia, under some circum-
stances, presents one of the most difficult of diagnostic problems, par-
ticularly when chronic. As in the case of the reducible forms, I shall
give the semeiology under two heads, as acute and chronic.
(a) Acute irreducible hernia represents a condition in which a recent
or ancient hernia becomes incapable of reduction by ordinary means,
and produces symptoms of such severity that surgical aid is at once
sought. An old hernia, hitherto perfectly reducible, may protrude
to such an extent, from the slipping of a truss or other accident, that
its bulk alone forbids an easy reposition. At other times, a small
knuckle of intestine may become distended with gas or the contents
of the bowel, and be too large to pass through the opening. In either
case, symptoms of urgency do not generally come on at once, but after
a time the parts become sensitive, inflammation, more or less acute, is
set up, and symptoms become rapidly worse, from this point common
to all varieties of acute strangulation. In many cases, the irreduci-
bility is characteristic of the first appearance of hernia.
An unaccustomed or unusually violent muscular effort is made, one
that has a tendency to make tense the abdominal walls, whereby the
capacity of the abdomen is much diminished, and the crowded viscera
seek release from the pressure by protruding through a convenient
outlet. The violence with which this act is accomplished probably
ruptures some of the fibres of tissues forming the canal; the peritoneum.
is exposed to more or less injury, and the same force has a tendency
to distend the portion of intestine prolapsed. There is a sudden pro-
duction of a tumor at the point of exit, with great pain, rapidly in-
creasing constitutional disturbance, with nausea, vomiting, and fruit-
less attempts at defecation; these latter symptoms have the effect to
still further increase the distension of the hernia. The pain gradually
increases until strangulation becomes complete, when it ceases in the
tumor, but continues in the tissues surrounding it. The vomiting, later
in the case, becomes stercoraceous, and hiccough is annoying. Unre-
lieved, the constricted portion of intestine becomes gangrenous, when
the tumor assumes a livid or bluish-black hue, and there is a crepitat-
ing sound on palpation, occasionally a cadaverous odor about the
patient. The skin becomes moist and clammy, the temperature falls,
the mind is more or less disordered, and death commonly ensues.
These last symptoms are modified somewhat, depending upon the char-
acter of the hernia, whether enterocele or epiplocele, the former being
naturally the most serious malady. In a few cases, very exceptional,
adhesions may occur between the prolapsed viscera and the walls or
margins of the canal, and life be preserved, with a permanently irre-
ducible hernia. In other cases, still more exceptional, the strangulated
tissue will slough off, the two extremities of the intestine become
united, and the continuity of the canal will thus be reëstablished. It
DISEASES OF THE ORGANS OF DIGESTION.
765
has even occurred that a fistula has formed, opening on the surface,
and life continued, although at considerable expense of comfort. As
a rule, however, the result is in death, if relief is not obtained.
(b) Chronic irreducible hernia is one in which a hernia has remained
unreduced after all acute symptoms have passed away, usually from
plastic adhesions. Such herniæ are chiefly troublesome from their
size, interfering with some bodily functions or movements, but are
not as innocent affairs as is popularly supposed. The existence of
adhesions, whilst usually a promise of immunity from later and addi-
tional protrusions, is no promise that dangerous symptoms may not
be set up. An accumulation of fæcal matter, or the entrance of some
indigestible substances, may set up inflammation, suppuration, or
gangrene, the fact that there is incarceration adding largely to the
danger. The symptoms of chronic irreducible or incarcerated hernia,
as long as acute inflammatory conditions do not appear, are often very
obscure. They are largely objective, and from the fact that hydrocele
and varicocele may easily become secondary and caused by the hernia,
sometimes even overshadowing the original malady, a diagnosis be-
comes very embarrassing. A careful study of the history of such cases,
bearing in mind that a hernia is often complicated by these diseases,
will usually enable the physician to reach a satisfactory conclusion.
Etiology. The causes of hernia naturally fall under two heads;
many serious mistakes in treatment have occurred from a failure to
recognize this fact.
(a) Exciting causes.-With a predisposition to hernia, either
congenital or acquired, the most common and, indeed, the sole exist-
ing cause for its appearance is a sudden, violent and usually involun-
tary diminished capacity of the abdominal cavity. Thus, severe
straining efforts, as in lifting heavy weights, are often found to be the
cause. When a severe muscular effort is made voluntarily, as a rule
the parts chiefly concerned are gradually placed in the best position.
to avoid injury, and the effort is voluntarily relaxed before damage is
done. But in involuntary acts, where some sudden and unforeseen.
effort is required, there is no such preparation to avoid injury. Thus,
the abdomen being suddenly compressed and its walls rendered un-
yielding, the capacity being correspondingly diminished, the viscera
being compressed beyond their capacity for such compression, if an
outlet can be found, some weak and unguarded portion of their envi-
ronment, they will make their escape thereby. All things being equal,
therefore, the inguinal canal in men and the femoral in women offer
the desired release, and through one or the other the hernia occurs.
The variety of forces that result in this compression are numerous,
and a short treatise, like the present, does not demand their full con-
sideration. The general fact being stated, special forms are readily
suggested to all practitioners.
766
A SYSTEM OF MEDICINE.
(b) Predisposing causes.-The predisposing or maintaining
causes of hernia are very numerous, partly as they affect all mankind,
and partly as relating to portions or families of the human race.
Under the first head, there are common anatomical arrangements ;
under the second, age, sex, occupation, race, and individual, congenital
peculiarities. I will consider each of them very briefly.
Anatomical peculiarities are the existence of a number of appar-
ently insufficiently guarded openings or outlets, or openings usu-
ally competent to resist protrusion, but accidentally rendered vulnera-
ble. Prominently, these are the inguinal and femoral, although a
classification given earlier shows that there are others. These open-
ings exist in all, and thus our very structure and plan of organization
predisposes man to hernia. But Velpeau has shown that ventral her-
nia has occurred through the small openings provided for the passage
of muscular branches of arteries. Thus, portions of fat have become
insinuated into these openings, have grown there, distended them to a
size sufficient to a portion of intestine, which is drawn in very fre-
quently by the peritoneum in relation to the fatty prolongation, being
drawn in with its increasing growth. Such causes for hernia are ex-
tremely rare, but they do occur. The occurrence of ventral hernia is
oftener due to injury. Thus a wound dividing a muscle heals with
considerable retraction or dispartition of the two extremities of the
muscle. The gap is filled up by an inelastic tissue, cicatricial, which
really alters the action of the muscle. Thus the rectus exerts its force
from the sternum and cartilages above to the pubis below. If divided,
the upper fragment terminates in the cicatrix in place of the pubis,
and the lower originates at the scar, and not at the sternum. Now
its action is that of two muscles pulling in different directions, and
exerting traction on the inelastic scar-tissue, it becomes thinned and
distended, offering such a feeble barrier to the protrusion of the viscera
that a hernia is readily produced. Taken together, these three ana-
tomical peculiarities may be considered representative of their class of
causative factors; the particular point of emergence of a hernia, there-
fore, depends upon accidental agencies, as one opening is better pro-
tected than another, or some peculiar character of the force applied.
Age has always been considered an important element in ætiology.
If we take the age, not when the hernia is seen by the surgeon, but
when it was first observed by the patient, the younger periods of life
seem to furnish more cases than the later. This is what would naturally
be expected when we remember the frequency with which the descent
of the testes is delayed.
Sex has not been found to exercise a marked influence in this direc-
tion, so far as hernia itself is concerned, although it does as to kind.
Thus there are more cases of femoral hernia among women than
among men; when the differences in occupation are considered, it
DISEASES OF THE ORGANS OF DIGESTION.
767
would appear that under the same conditions or circumstances there
is no reason why women should be exempt.
Occupation is supposed by many authors to play a highly important
part in causation, and rightly so, but in a slightly different manner,
so far as my own experience goes, than is popularly supposed. Thus
it is generally stated that laborious occupations furnish more cases
than others. Mr. Kingdon (London Truss Societies' Reports) has made
very careful inquiry in this direction, and finds that the number of
herniæ in each class of any occupation is determined solely by the
number in each class, and not the kind of labor. A moment's reflec-
tion, it seems, would show that the greater the muscularity, other
things being equal, the greater the protection. We would find hernia,
therefore, less often among those who are inured to laborious occupa-
tions; and such has been my experience. I have found more cases
among bookkeepers, clerks and men of some leisure than among labor-
ing men.
Race, so far as our records go, would seem to negative the foregoing,
as among Arabs, Egyptians, and people of equatorial climates there
does not seem any disposition to hernia, at least not greater, in spite
of their indolent habits, than among other people. We will remember,
however, that the lower orders are frequently hard working and indus-
trious, with proverbially muscular, although spare, figures. The higher
classes have little, if any, provocation to physical exertion, and hence
are not exposed to those agencies that produce hernia.
The vaginal process of the peritoneum must be considered as a pecu-
liar provocative of hernia, owing to a somewhat common abnormality.
As the testes descend into the scrotum they push before them a por-
tion of the peritoneum which becomes the tunica vaginalis, the por-
tion in relation with the cord and the inguinal canal becomes obliter-
ated and converted into a cord, under normal conditions. Occasion-
ally it remains open, and a portion of intestine, finding its way into
this funnel-shaped opening, gradually distends it until it has passed
out of the abdominal ring, when it becomes a hernia. This patency
of the vaginal process, therefore, must be considered a predisposing
cause of the first magnitude, and it is so esteemed among careful
students to-day.
Elongation of the mesentery must be considered as closely related to
the former. Even with a failure to close the vaginal process, if the
capacity of the abdomen is sufficient for its contents, a hernia may
never occur. But if from congenital defect the mesentery is abnor-
mally long, the contents are practically increased in bulk, and on proper
provocation a hernia occurs. The mesentery being abnormally long,
with the vaginal process closed, a hernia is more probable than were
this not the case.
It can be at once credited, it would seem, that hernia may easily be
768
A SYSTEM OF MEDICINE.
hereditary. A parent with an old hernia has necessarily a long me-
sentery. The probabilities (or possibilities) are that his offspring will
have a similar defect, and thus, with weakness about the inguinal
canal, or late closure of the vaginal process, a hernia is very easily
produced. I certainly place these last two conditions in the first class
of predisposing causes.
Prognosis. The prognosis of hernia is to be based entirely upon
its reducibility. As long as a hernia is reducible, and can be retained
with a suitable and properly constructed truss, so long is the prognosis
good as to continuance of life. Should it be retainable with difficulty,
either from faulty truss or unusual size of the openings through which
it protrudes, there is constant danger of strangulation, and the prog-
nosis becomes bad. If incarceration occurs, death is imminent, and
if it is escaped it can be attributed often to lucky accidents. Under
all circumstances, however, a hernia of any kind, reducible or other-
wise, is a menace to life, and in proportion to its reducibility is the
menace lessened.
Treatment. There can be no question that the treatment of
hernia is largely a question of surgical interest, and must, therefore,
be passed over very briefly in this place. Nevertheless, there are
items in the treatment that have a relation to purely medical practice,
and to such I shall largely confine myself.
The first consideration, in a recent case, is to secure perfect reduc-
tion, and then to procure retention with a suitable truss. Should the
subject be young and the disposition to return of the hernia marked,
there is a strong presumption that there is both an elongation of the
mesentery and patency of the vaginal process. The effect of retention.
in such a case can only be considered palliative, as, the contents of the
abdomen being too voluminous for its capacity, should a descent of
the viscera be prevented at one point, it will likely occur at another.
Should the case, on the other hand, be an acute traumatic one, particu-
larly in an adult, reduction and perfect retention should prove curative,
inasmuch as the very fact of traumatism promises a solid repair if
taken in hand sufficiently early. Under all circumstances, therefore,
complete reduction is the first indication, as perfect retention is the
second, and the disposal of any predisposing conditions that may be
accessible the third. In ancient cases, or those in young subjects, con-
genital in character, any attempt to close the outlet by medicines.
must fail; nothing but a surgical operation can do this, and the case
must be referred to a competent practitioner. The mesentery being
shortened, one leading, perhaps controlling, element in causation is
disposed of, and this can often be attained by medical treatment.
Not unfrequently the recession of the protruded viscera produced by
this shortening of the mesentery is followed by a closure of the peri-
toneal process, and an additional barrier thereby interposed against
DISEASES OF THE ORGANS OF DIGESTION.
769
reproduction. Lycopodium and Calcarea carb. have been extensively
used for this purpose, and the results are sufficiently voluminous to
give assurance of reliability. The indications for the remedies are
entirely general in character, and need not be noted at length. There
are very many cases reported of a remedy having been used for a dif-
ficulty unconnected with hernia, apparently, with no intention of
affecting the latter condition, in which the hernia has likewise disap-
peared. Argentum and Sulphur are both credited with such cures.
In cases of irreducible hernia different considerations obtain.
While remedies are of value, yet it is my opinion that lives have been
lost by relying upon them to the exclusion of the operation. Statistics
are abundant, proving beyond a doubt that deaths from herniotomy
are comparatively rare; perhaps almost uniformly a cure is secured
if an operation is made early. On the contrary, when it has been de-
layed, or the parts subjected to rough usage, bruised and inflamed
from long-continued efforts at reduction, death is a common occur-
rence. In the one case, we return an intestine to the abdomen only
slightly irritated from the constriction; in the other, one partially de-
vitalized, and perhaps beyond the possibility of recovery. Further-
more, success with taxis, or other means for reduction, leaves the parts
concerned in a suitable state for a reproduction of the accident; in
other words, the result is palliation, postponing the final result. An
operation often, and nearly always, results in a radical cure. There
are additional reasons why radical operative measures should be pre-
ferred to timid, uncertain and blind medication. Accidents are not
uncommon, under taxis or other methods of reduction, accidents that
often put the patient immediately beyond the hope of recovery, and
render even an operation useless. For instance, the hernial pouch
may be ruptured, and the contents poured out into the peritoneum ;
the peritoneum may be torn, and the knuckles of intestine strangu-
lated in the rent, so that reduction of the tumor may not release from
constriction. Finally, the use of remedies and taxis may be continued
for so long a time that gangrene occurs, and while an operation may
even then be successful, yet it is a somewhat problematical, and at all
events a very formidable undertaking. For these and other equally
cogent reasons, I am decidedly opposed to temporizing treatment, and
counsel early operation in cases of strangulated hernia, both as a means
for present relief and permanent cure. I will simply mention the fact
that Nux vomica, Opium, and Plumbum have long enjoyed a reputation
for reducing strangulated hernia. They may be used if the case is
very recent, and in connection with them slight or rather very briefly
continued taxis, or application of cold. If the physician is wise, and
correctly reads the lessons furnished by the records of the past, he will
refrain from all such palliative, uncertain and dangerous practices,
and perform herniotomy, or call in competent surgical skill to perform
VOL. I.-49
770
A SYSTEM OF MEDICINE.
it for him.
Should reduction be readily effected, a truss or some suit-
able retentive dressing must be'applied and worn until all danger of
a return seems to be averted. Incarcerated hernia is a purely surgi-
cal subject, and foreign to our present inquiry.
ULCERATION OF THE BOWELS.
BY J. G. GILCHRIST, M.D.
Ulceration of the bowels, in which term are included both the small and
large intestines, may be symptomatic or idiopathic; very often, per-
haps in the larger number of cases, it is the former. In this connection
the term symptomatic is used to express an ulceration which constitutes
a symptom, either characteristic or accidental, of some recognized
morbid condition or accident. Thus, in medicine we have a familiar
example in typhoid fever, and in surgery in cuticular burns or scalds.
Idiopathic ulceration, on the contrary, represents something uncon-
nected with other recognized morbid states, either from traumatism or
from intestinal diseases more or less obscured by the ulceration. As
far as the pathology of either form of ulcer is concerned, there exists
much unnecessary confusion, the conditions resulting in ulcer being
the same, no matter what tissue is the seat. Prognosis, however, is in-
terested in intestinal ulceration, and more especially in the symptom-
atic group.
Pathology.-Ulceration, under all circumstances, and this is the case
in all tissues, can never have any different origin than inflammation.
Next to suppuration this process is the commonest termination of in-
flammation. The particular question of interest, therefore, in the present
instance will be the causes for the inflammation, particularly when
the ulceration is associated with a morbid condition existing or start-
ing outside of, and at a distance from, the intestinal tract. Ulceration
may always be expected and predicted when the inflammation is
intense, localized, stasis marked, and effusion defective. It represents
a condition of exaggerated molecular waste or loss, a granular disinte-
gration of the tissues under observation. It does not so frequently
complete devitalization as when the circulation is entirely cut off, for
then we have death of the part in masses, gangrene, and sloughing.
Should it result from traumatism, it represents a defect in repair, a
minus as to organization, while production is not necessarily deficient.
It argues local or general adynamia. Hence, any cause for inflam-
mation is a legitimate cause for ulceration, as well as any local and
circumscribed removal of vascular tissue, under circumstances that
might interfere with repair. It appears that Erichsen (Science and Art
of Surgery) has most happily classified the conditions favorable to
DISEASES OF THE ORGANS OF DIGESTION.
771
ulceration, and while his scheme applies more particularly to cuticular
ulcers, as the form oftener presented to the surgeon, yet it applies.
equally well to the present form. Thus, one of three conditions of
local mal-nutrition must obtain. 1st. Deposition is normal, and ab-
sorption excessive; 2d. Absorption is normal, and deposition is de-
fective; 3d. There may be a simple throwing off of dead, spoiled matter.
It requires no commentary on the above to show its suitability as an
explanation of all forms of ulceration. In the case of the intestines,
particularly organs engaged at once in nutrition and elimination to a
greater degree than almost any other organs in the body, the condi-
tions for ulceration are most abundantly supplied. This vulnera-
bility is largely increased by the compensatory function of emuncto-
ries generally. Thus it is stated that the defecation of the body is
little, if any, less important to its well-being than its nutrition.
The amount of effete material, gaseous, fluid, and solid, that is
thrown off in a single day, through the lungs, the kidneys, the bowels,
and the skin, is actually enormous. Should this elimination be sup-
pressed at one point, other emunctories must have an increased amount
of work thrown upon them, or the arrested excretion remains in the
body, producing more or less disastrous effects, depending upon its
kind. In many instances, either through double organs, as the kid-
neys, or associated organs, as the lungs and skin, a suppression at one
point may be compensated at another. Should this increased effort
of a duplicate or alternate organ be unduly continued, serious conse-
quences must ensue. Prominently the hyperæmia that normally
attends vital effort may, and does very easily, pass over into inflam-
mation if the function is too energetically performed. Inflammation,
being always destructive and pathological, induces lesions that still
further complicate matters, and a common lesion is ulceration or a
molecular waste, which corresponds to that condition. We may now
be prepared to understand how it is that ulceration of the bowels may
be concomitant of morbid action that would not, at first sight, appear
to have any relation to the intestinal tract.
In view of the fact that an ulcer of the intestines presents the same
pathological features attending ulceration of other tissues, it is neces-
sary to consider ætiology and pathology simultaneously. For con-
venience of description it has been the custom to classify ulcerations of
the bowels under two heads, viz., those originating from without the
intestine, and those from within. The most objectionable feature in
this classification is that the first group only includes morbid action
developed in parts contiguous to the intestinal ulcer, while, as a matter
of fact, as we shall see later, the causative morbid action may be very
far removed. I subdivide the first group, therefore, into local causes
and those operating at a distance. My scheme may be thus tabu-
lated:
772
A SYSTEM OF MEDICINE.
(Traumatic.
Inter-intestinal
Idiopathic.
1.
(Contiguous lesion.
Extra-intestinal {Remote morbid action
Traumatic
or
Symptomatic.
(a) Ulcers arising from morbid action or traumatism within the
proper tissues of the intestinal canal, furnish by far the largest number
of cases. There is no portion of the canal exempt from ulceration,
and yet the duodenum, the last portion of the ileum, the cæcum, the
sigmoid flexure of the colon, and the rectum seem to be favorite seats.
There is some significance in this, more particularly, however, in rela-
tion to extra-intestinal cases. In the present instance, the circum-
stances governing selection of site seem to be some alteration in the
direction of the canal, furnishing more or less obstruction to the
motion of the contents of the bowels, and at the same time acting, in
some sense, as a separator. Thus the beginning and end of each sec-
tion of the intestines, the one admitting the food acted upon by the
secretions of the stomach, nutritious and innutritious alike, and the
other thrusting out, as it were, that which has been rejected as unsuited
to the purposes of the body, supply conditions that may well be con-
sidered eminently favorable to ulceration. The duodenal portion of
the canal is largely interested in digestion, supplies a secretion of its.
own, and receives that from the common duct, arguing considerable
vital activity, predisposing to inflammation. Any fragment in the
mass received from the stomach of a consistency or other character
that has resisted its disintegrating action, or that is specifically irritant,
may well be causative of inflammation. At the termination of the
small intestine there is a constriction of the canal, and the ileo-cæcal
valve which, to some extent, perhaps greater than is ordinarily sup-
posed, predisposes to the arrest of particles of the ingesta, thus retain-
ing putrefiable material within the body, which alone would be a
source of danger and an eminently competent cause for ulceration.
In the same manner indigestible foreign material may thus be arrested,
and cause either suppuration resulting in an ulcer, or ulceration from
absorption. The cæcum is occasionally a point of arrest for fæcal
matter, its location and general characters making it somewhat a source
of wonder that such accidents are not of more frequent occurrence.
At the sigmoid flexure the same natural and anatomical predisposition
is found. The same remarks apply to the rectum, where we have a
narrowing of the calibre at both ends, and an almost constant accu-
mulation of dejecta in many, if not all, individuals. It is thus very
apparent that the anatomy of the intestinal canal, as well as its func-
tion, predisposes to the essential conditions of ulceration. Should
sharp or hard and irregular foreign material, such as pieces of bone,
or other insoluble substances, be admitted into the intestines, a lacera-
DISEASES OF THE ORGANS OF DIGESTION.
773
tion of the mucous coat may readily occur, and a wound once inflicted,
an ulcer is very easily produced.
There is another occasional cause of ulceration, one that should, it
would seem, be often operative. This is the lodgement of particles from
the ingesta behind the mucous folds of the intestine, the valvulæ conni-
ventes. Their function, it is supposed, being largely to retard the pas-
sage of the intestinal contents, and thus give greater opportunity for
the absorption of the nutrient portions, it would necessarily be an
easy matter for particles to lodge, and give rise to inflammation and
consequent ulceration.
Thus far we have had to do with ulceration arising from causes
operating from within the intestinal canal, primarily upon the mucous
coat. There are other methods and causes, however, possibly equally
important. Morbid action may commence in the muscular coats, or
the subserous, and thus reach the mucous surface. These are nearly
traumatic in character, something in the nature of a contusion, whereby
ecchymosis is produced, or capillary extravasation is secured. Such
ecchymosed spots must necessarily favor ulceration, if the parts are
otherwise so disposed.
(b) Ulceration arising from conditions operating or originating at a
distance from the intestinal tract, those extra-intestinal in character, is
not difficult to comprehend or account for. The first step in the pro-
cess of ulceration must be an arrest of excretion somewhere. In some
forms of fever there is suppression of cutaneous excretion, a diminu-
tion in that from the kidneys, the bowels are sluggish and inactive,
and even the breath is hot and dry. In such a condition, if life is to
be continued, the remaining emunctory, the intestines, must be actively
engaged. The portions of intestine particularly of interest in this con-
dition are naturally those in which the largest number of glands and
follicles are found. These portions are the duodenum, the first part
of the jejunum, and the last part of the ileum. It is at these points
that ulceration usually occurs, and on any sufficient provocation.
The increased activity of these glands, to compensate for the loss
of function in the other eliminators, induces a necessary hyperæmia.
From the general condition of the body, the changes in the blood (in-
creased fibrin) consequent upon the fever, and abnormal functional
activity of the parts, inflammation readily succeeds the hyperæmia.
The arrested nutrition of the body and the augmented molecular waste
combine to make this inflammation one of considerable intensity, with
unusual disposition to stasis. Ulceration at these points is an almost
inevitable consequence. The ulcers secondary upon remote or general
lesions are, therefore, oftener duodenal, from the glands of Brüner, or
lower down from breaking down of Peyer's patches.
Ulceration, extra-intestinal in character, but from contiguous morbid
action, occurs from such lesions as inflammation of other viscera, re-
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A SYSTEM OF MEDICINE.
sulting in suppuration, a connection being established between the
abscess and the intestine. Such occurrences are not by any manner
of means rare, but the ulcer is usually of short duration, healing as
the morbid action back of it disappears. Should it remain open for
any time, however, particularly if the abscess with which it is in rela-
tion should become chronic, it cannot properly continue to be called
an ulcer; it is then more correctly a fistula or sinus, being of second-
ary importance to the lesion with which it is associated.
The colon seems to be affected by a peculiar form of inflammation,
commonly spoken of as "croupous," in which there is a fibrinous ex-
udation, somewhat friable in texture, which dips down between and
into the follicles, accompanied by much thickening and "congestion,"
as some call it, of the deeper parts. Upon the detachment of this
adventitious membrane the parts are excoriated and raw, a condition
which is much aggravated by the constant irritation to which the sen-
sitive surface is exposed by the passage of the fæces over it. In fact,
a similar exudation on a surface not exposed to such an irritation
might, and usually does, remain as a protective to the deeper parts,
until it has matured, and then desquamates or exfoliates, leaving a
sound surface. It is very likely, therefore, that in croupous inflamma-
tion of the colon the passage of the fæces, which are supposed to move
steadily along the canal, loosens and detaches the membrane prema-
turely, and then follows up this mischief by converting what might
have been considered an abrasion into an ulcer.
Although many of the systematic works on practice and special
pathology devote much space to this subject of non-specific ulcer-
ation, I prefer to treat it as purely supplemental to the pathology
of ulceration in general; ulcers in all parts of the body, as already
remarked, are produced in much the same way, the variety of causes
being actually repetitions of each other, with often merely insignifi-
cant modifications growing out of differences of location. If this is
true of the non-specific ulcers, it is certainly equally so of the specific.
Tubercular, strumous, carcinomatous, and syphilitic ulcerations have
been already described in other chapters of this work, and need no
additional mention at this time.
Semeiology.-The symptoms of ulceration of the bowels, apart
from conditions with which they may be associated, are not at all pro-
nounced; they depend for the most part on the portion of the canal
involved. While this is true of many cases, yet there are instances in
which the symptoms are marked and severe, the ulceration being, as
it were, the most significant feature of the case. As might be inferred,
the condition originating in an inflammation, the earlier symptoms
are febrile in character, and more or less pronounced as the inflam-
mation is intense or otherwise. The tongue shows the characteristic
signs of gastric or intestinal irritation, and there may be more or less
DISEASES OF THE ORGANS OF DIGESTION.
775
well-defined pain or sensitiveness at some point in the abdomen, par-
ticularly on pressure. Such pain or sensitiveness as there may be is
localized, not at all diffused, so that the lesion may often be definitely
placed. These symptoms are in the nature of prodroma, although
they rarely appear until the ulceration is accomplished, or, if they do
so, they are insignificant, and do not attract much attention from either
the patient or the physician. Later, and very soon after the above
indications become prominent, others, depending upon location, be-
come quite pathognomonic. Under all circumstances, the bowels, to
use a common expression, become disturbed. In the majority of cases
diarrhoea, more or less approaching dysentery, is the form of disturb-
ance, but in some cases it is constipation. Probably, judging from
the imperfect records in this particular, the higher in the intestinal
canal the ulceration occurs, the greater the probability that constipa-
tion will be the result. Consequently, something can be attempted in
the way of localizing the ulcer by observing the character of the stool.
The stools being diarrhoeic, they should be inspected with a view to
determine the presence of blood, mucous shreds, or other evidences of
ulceration. When the ulcer is in the ileum, the blood, if there be any
present, is in a more or less coagulated form, but has been observed
fluid. It may not be amiss, in view of the fact that I have witnessed
some very ludicrous misapprehensions on this point, to state that blood
from the small intestines very rarely appears in the stool in the ordi-
nary characters of that fluid. It is usually black, may be tarry or
fluid, in short, the stool of Leptandrin, as given in our Symptomatologies,
describes it exactly. It may not be in large amounts, often a mere
streak or speck, and yet in other cases be poured out in considerable.
quantities from an opening of a vein, or even an artery of size. There
are cases in which the hæmorrhage has been sufficiently profuse to
destroy life, but ordinarily it is as given above.
Ulceration of the colon, particularly of the lower portion, gives symp-
toms very frequently observed in dysentery. This disease forms the
subject for a separate treatise in this work, and need not detain us
here. Suffice it to say that the bloody stools, the small amount of
fæcal matter therein, and the shreds of tissue from the bowels form
very characteristic features of ulceration. In this case, however, we
find a symptom peculiar to the region, namely: tenesmus from the
irritability of the sphincters.
Therapeutics.-Considering the treatment of intestinal ulceration
to be essentially for the ulcer, and with no reference to associated con-
ditions, all reference to typhoid fever and dysentery, except of a very
general character, must be omitted. The reader is referred to the ap-
propriate chapters for details in these particulars. The treatment is
almost, if not entirely, by means of remedies given on characteristic.
indications. Of course, if the cause of the ulceration is apparent, and
776
A SYSTEM OF MEDICINE.
it should be of a character to threaten a return or continuance of the
trouble, it must be removed, or as far as possible guarded against. No
instruction can possibly be given on this point; in this particular
each case must be considered by itself. Being entirely dependent
upon subjective indications, the objective symptoms of the stool being
common to all forms of ulceration, the list of remedies is necessarily
much shorter than is the case in cuticular ulcers. And yet, an ex-
haustive presentation of therapeutics would include all the remedies
useful in diarrhoea and dysentery. Those which would seem to have
particular relation to ulceration are here given, reference being had
for additional remedies to the chapters on diarrhoea and dysentery for
further particulars.
Argentum nitr.-Diarrhoea as soon as he drinks. Stool green; flaky, like
spinach, mucous, bloody, with tenesmus.
Arnica mon.-Involuntary stools during sleep; brown, fermented stools, with
fetid breath and loathing of food; offensive, papescent, involuntary stools.
Arsenicum alb.-Black, acrid, putrid stools; rapid emaciation; dryness of
skin; thirst for small quantities, cold drinks excite vomiting.
Baptisia.-Dark, brown, mucous, and bloody stools, with typhoid tendency;
stools very offensive.
cus.
Capsicum.-Stools frequent, small, mixed with black blood and tenacious mu-
Carbo veg.-Stools frequent, involuntary, putrid, cadaverous-smelling; stools
bloody, sometimes causing fainting.
Elaterium.-Dark green, mucous stool, mixed with white mucus streaked with
blood.
Leptandra virg.-Before stool, loud rumbling and gurgling in abdomen as of
water, seeming to start from the stomach; profuse, black, papescent, tar-like, very fetid
stools, followed by severe cutting pains in the small intestines; after stool, faint, weak,
and hungry.
Mercurius corros.-Cold face and hands, with small and feeble pulse; the
limbs feel bruised, and tremble. Stools small, frequent, bloody, mucous, with great
tenesmus, before, during, and after stool; stools largely mucous.
Phosphorus.-Watery diarrhoea, sometimes pouring away from the bowels
like water from a hydrant, suddenly becoming bloody; almost pure blood, with great
weakness and prostration.
Sepia.-Chronic, debilitating diarrhoea; frequent, not profuse, jelly-like, green or
bloody stools, with nausea and colic before, prolapsus ani during, and exhaustion after
stool.
Silicea,—Frequent desire for stool, with chilliness and nausea; stools of bloody
mucus, or brown fluid and bloody, smelling offensively.
Sulphuric acid.—A sensation of trembling in the body, without visible
trembling; bloody stools, with empty, exhausted feeling in the abdomen afterwards.
For other remedies, probably not as often indicated, see under Diar-
rhœa or Dysentery, the following: China, Dulcamara, Ipecacuanha, Nux
vom., Pulsatilla, Rhus tox., Sulphur, or Asar. europ., Bryonia, Calcarea
carb., Chamomilla, Dioscorea, Ferrum, Hepar, Kreasotum, Lycopodium, Ni-
tric acid.
DISEASES OF THE ORGANS OF DIGESTION.
777
CARCINOMA OF THE INTESTINES.
BY J. G. GILCHRIST, M.D.
With the exception of the stomach and rectum, the bowels are not
very frequently the seat of carcinoma ab initio: when so affected, it is
nearly always as an extension from cancer of contiguous parts. It is
difficult to understand why this immunity should exist, the tissues
not being at all different from others which are very frequently the
subjects of cancer. Inasmuch as carcinoma of the stomach and rectum
receive attention in their proper place, the present subject must of
necessity be very briefly presented.
The chief point of interest is in the results of cancer in this region,
and apart from some considerations growing out of function even they
are very similar to the effects observed on all tubular organs. The
pathology, ætiology and semeiology, with similar exceptions as above,
are the same as in carcinoma occurring elsewhere, and need no particu-
lar mention. Scirrhus, encephaloid, colloid and melanosis occur in
about the same order of frequency as elsewhere; the two former are
likewise oftener primary, and the latter secondary or recurrent.
Scirrhus perhaps oftener appears as a primary disease, and in very
much the sarne manner as in the peritoneum, already noticed; that
is, there is a deposit of granules or small masses, gradually becoming
aggregated and forming either a tumor or patches. I am of the
opinion that scirrhus is oftener deposited in a stratified form, follow-
ing, for a time, the line of separation of the different tunics of the
bowel, but soon exerting its characteristic action on the parts with
which it is in relation. The first effect will be to stiffen the walls of
the intestine which very materially interfere with its function. Next,
the glands and follicles are destroyed, the various parts are aggluti-
nated, fused together, and the calibre of the tube diminished by the
contracting power of the scirrhous tissue. Whether the deposit occurs.
on the sub-serous, the mucous, or in the middle coats, the result is the
same; the whole thickness of the part becomes implicated, the peri-
toneum becomes adherent and takes part in the morbid action, and
neighboring viscera are likewise brought under its influence. From
the peculiar anatomy of the intestines, dispersion of germinal elements
very speedily occurs; hence there are usually early secondary deposits.
and a rapid establishment of cachexia. Perhaps when the deposit is
first made on the fibrous or subserous side, these later symptoms may
be sometimes delayed, but the whole course of the disease, I have
thought, is much more rapid than when other tissues are affected.
Finally, the intestine becomes constricted or narrowed until a stric-
ture is formed, the passage of its contents is more and more difficult,
until, at last, there is total occlusion and speedy death. The occurrence
778
A SYSTEM OF MEDICINE.
of occlusion is never sudden; there is always increasing urgency in
the symptoms of stricture, until there is evident total obstruction, with
accumulation of gas and ingesta, so that a mistake in diagnosis is very
rare indeed. This is particularly true from the fact that cachexia is
generally well established before obstruction occurs, and there are also
probably other cancerous formations or deposits, secondary in char-
acter, which forbid any mistake in the majority of instances.
Encephaloma, as well as colloid, differs in some particulars from
scirrhus. Thus neither is liable to occur in a stratified form, but
assumes tumor-characters from the first. Occurring on the mucous
surface, they grow rapidly, and while not exhibiting any tendency to
contract the parts, or to draw other parts into them, they produce all
the symptoms of constriction or obstruction by the growing mass fill-
ing the lumen of the organ. When the canal is filled with the tumor,
it speedily contracts intimate adhesions to all sides, and near parts of
all characters become partakers in the morbid action. As was found.
to be the case in colloid of the stomach and peritoneum, contraction
and fusion of near-lying parts often occurs. This is rarely the case,
however, with encephaloid; the tendency here being to amplification,
tumor forms.
Melanosis is rarely found as an independent growth or deposit.
When occurring at all (and it is among the most unfrequent of car-
cinoma), it is associated with encephaloid or colloid, sometimes with
scirrhus. When with the former, it appears as an infiltration, or in
small tumor-like masses. When in connection with scirrhus, it is
oftener punctiform.
The symptoms of carcinoma of the bowels are very obscure in the com-
mencement, very closely resembling ulceration. Diarrhoea is present
in nearly all cases, constipation being more common, perhaps, when
the disease is high up. The evident malignant character of the symp-
toms, their persistence and steady increase in intensity, the rapidly
increasing cachexia, and the occurrence of severe and exhausting
hæmorrhages are of a character to leave little room to mistake the in-
dications. As to hæmorrhage, my opinion has been that carcinomatous
ulcers more frequently open large vessels than any other form of ulcer-
ation. This is particularly true of the arteries, whose coats seem to be
singularly resistant to morbid action. When hæmorrhage is abundant,
therefore, particularly if arterial, more especially should it be frequently
repeated, there is good ground for supposing that the condition giving
rise to it is carcinoma.
Prognosis, as in all cases of cancerous diseases, is bad. Cancer
of the bowels, more particularly scirrhus, is almost uniformly fatal.
There are a very few cases on record, infinitesimal as to the whole
number of cases of cancer, in which a tumor has been cast off by
ulcerative action, the ulcer which remained promptly disappearing,
DISEASES OF THE ORGANS OF DIGESTION.
779
leaving no trace of the specific disease. These few and isolated cases
must not encourage the medical attendant to give a hopeful prognosis,
for the conditions upon which such terminations are based are so ex-
ceptional that nothing can be founded upon them. The rule is that
death will occur, and more speedily than is the case when the cuticular
surfaces are chiefly affected.
to us.
Treatment is purely palliative. It is possible that cases have been
cured in the incipient stages, but data are then wanting on which to
base a diagnosis. Carcinoma being fairly established, it is more than
questionable if a cure is possible by any means or methods now known
At least, we have no authentic records of such cases; if any are
found scattered through our periodical literature, the symptoms and
conditions on which a diagnosis was made are so carelessly given that
no reliance can be placed upon them. If remedies are used, they would
be given on indications furnished by the symptoms of the stool, and
hence reference must be had to the articles on Diarrhoea, Dysentery,
Constipation and Ulceration of the Bowels.
DISEASES OF THE RECTUM AND ANUS.
BY J. G. GILCHRIST, M.D.
CONGENITAL IMPERFECTIONS.
Whilst congenital malformations, or arrest of development, may
always be considered as only remediable by the resources of surgical
art, yet a brief review of the subject forms a proper introduction to
that which is to follow.
Imperforate anus seems to be by far the most common of these struc-
tural and congenital malformations. So frequent is this occurrence,
in one form or another, that thorough obstetricians always carefully
inspect the anus of newborn children, to receive early information of
any defect that may imperil the life or future happiness of the child.
An imperforate state may exist with or without corresponding imper-
fection in the rectum. Thus the rectum may be perfect and the anus
closed, the rectum may be deficient, or the rectum may be wholly want-
ing. The commoner form is that in which the rectum is perfect and
there is an absence of an anal opening. This condition may be due
to adhesions from various causes, in which case there will be some
external mark of a previously patent anus; or there may never have
been such an opening, in which case the perinæum gives no appear-
ances that would point to the position of the end of the rectum.
Either of these forms may be considered as constituting a decidedly
minor degree of imperfection, inasmuch as a comparatively simple
operation may put the parts in a normal condition, at least as to a
satisfactory establishment of their function. Should any doubt exist
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A SYSTEM OF MEDICINE.
concerning the condition of the rectum, a delay of a few hours, by
permitting an accumulation of the meconium, will usually furnish a
suggestive fulness in the perinæum, marking, at the same time, the
location of the anus.
A form of imperfection having more relation to the rectum than to
the anus is where the latter terminates in a cul-de-sac, at a varying dis-
tance from the anal border. This may be due to a septum, adhesion
of opposing rectal surfaces, or to a deficiency in the rectum itself.
Under the two former conditions the accumulation of meconium will
cause the termination of the cul-de-sac to bulge outwards, and thus
give evidence of the patency of the rectum. The failure of such bulg-
ing would be presumptive evidence of the absence of a rectum,
although, should the obstruction be due to adhesions, a long adhesion.
might prevent any such descent of the deeper portions of the tube.
Other abnormalities connected with imperforate anus are numerous,
chiefly relating to deficiencies or abnormalities of the rectum. Thus
there may be:
Opening of the rectum into the bladder in either sex. The absence of
the anus, and no signs of distress in the infant, with the appearance
of meconial or fæcal matter in the urine, would at once indicate the
nature of the anomaly. Life may not be at all prejudiced by this
unfortunate arrangement, and during childhood, at least, no serious
inconvenience will result. Later, however, the abnormality would be
a constant and prominent mortification to the sufferer, and surgical
counsel should be sought.
The opening may be into the vagina, and present indications that
would seem to be unmistakable. For similar reasons to those above
given, the condition may be considered of comparatively trifling
moment in infancy and childhood, but becomes an exceedingly
embarrassing one after maturity.
There may be an opening of the rectum in the inguinal region or in
some other parts of the abdominal walls, constituting an "artificial
anus."
With the rectum deficient, in part or wholly, there may be a consid-
erable deficiency of other portions of the colon. The variety of such
abnormalities is very large, almost everything conceivable having been
observed, in some cases the smallest portion of the colon, little more
than the cæcum, being found; in some rare instances the defecation
occurred through an opening from the ileum. Many of these defects,
it is self-evident, are naturally and radically irremediable.
Narrowness of the anus is the last on our list of the commoner forms
of congenital imperfections, and the characteristics are sufficiently
indicated in the name.
It is evident that some of these abnormalities are the result of an
arrest of development, others of malformation, and still others of
DISEASES OF THE ORGANS OF DIGESTION.
781
morbid action occurring during the uterine life. The latter, when the
condition can be made out, may be curable by electrolysis, by Silicea,
or other remedies, in case of cicatricial constriction or adhesion; yet a
As a
proper surgical operation is to be preferred in even these cases.
matter of fact, however, the exact diagnosis is rarely attainable.
Even a cul-de-sac may represent a termination of the bowel, the
remaining portion terminating in like manner above the brim of the
pelvis. Such cases must, therefore, always be viewed with solicitude,
and no steps taken, particularly surgical in character, without such
counsel as can be obtained.
HÆMORRHOIDS.
Piles, as they are otherwise called, are tumors growing from, or in
connection with, the mucous surface of the rectum, composed of di-
lated and enlarged veins, in the commencement, but later materially
changed in structure by exudation and extravasation. It has long
been the custom to classify hæmorrhoids with reference to their loca-
tion into internal and external, the former occurring inside, and the
latter outside, of the sphincters. The arrangement is a perfectly
natural one, and quite as much so from the fact that the structures
of the two kinds are different as from the mere consideration of loca-
tion.
External hæmorrhoids are small tumors at the verge of the anus,
often more than one, in the first stage composed of dilated vessels, with
some swelling and inflammation of the overlying mucous membrane.
After a time, usually a day or two, the swelling will subside, either
from a rupture of the vessel or a sort of partial resolution from coagu-
lation of the blood, and only a slight fulness remains to mark the seat
of the trouble. Some local irritation may subsequently occur, and
the tumors again become distinct, enlarged and inflamed, a less perfect
resolution succeeding. In process of time, the integument in the region
becomes thickened, the cellular tissue infiltrated, and the veins per-
manently enlarged. The swelling thus goes on increasing in size and
hardness, not always productive of pain, but quite generally sensitive.
At times they will become inflamed, very painful, and then all symp-
toms will disappear for a time. The pain, during an attack of inflam-
mation of hæmorrhoidal tumors, is most intense; the tumors them-
selves are turgid and hot, the skin in the neighborhood is red and in-
flamed, the cellular tissue is additionally infiltrated; there is a dis-
tressing fulness in the anus, producing tenesmus, and yet the pain
caused by even the passage of flatus is so great that every effort is
made to repress it. Finally there is an escape of blood, either exter-
nally or into the cellular tissue, with a somewhat rapid subsidence of
the acute symptoms or a more gradual and imperfect resolution,
782
A SYSTEM OF MEDICINE.
requiring some days. Under either circumstance, however, it results.
in increase of the size of the tumors and of provocation to subsequent
attacks of inflammation.
It is a popular belief that constipation is almost a necessary factor
in causation. This is only partly true. Diarrhoea is not less impor-
tant in this respect. There are two governing conditions, as a matter
of fact, somewhat different in character, and yet not different in
some important particulars. These are causes operating to produce.
venous engorgement and stasis, and those which induce atony of the
parts concerned. Errors in diet may operate through either class.
Walking, excessive venery, sedentary pursuits or habits, constipation,
pregnancy, and, in short, anything which may determine an increased
amount of blood in the part, and impede its exit, may be considered
predisposing causes. There seems to be little question that hereditary
influences play an important part in ætiology. It is very common to
find such a predisposition running through an entire family.
A hæmorrhoidal tumor, once formed, rarely disappears entirely un-
aided by art. The occurrence is the precursor of many subsequent
attacks, and at last they may become so numerous and so large that
they are a constant annoyance and a source of much discomfort. As
to size, there is very great variation; the tumors vary from the size of
a pea to that of a walnut. The same variation exists as to numbers;
in some cases two or three tumors may be found, while in others the
anus may be completely surrounded by them.
When the hæmorrhoidal affection becomes chronic and the number
of tumors is considerable, the appearances very closely resemble con-
dyloma; observing, however, that there are periodical attacks of acute
inflammation during which the tumors are increased in size, and that
these attacks are followed by an augmentation of size, with a more or
less abundant hæmorrhage at the close of the attack, there can be no
question as to the nature of the malady. Furthermore, the repeated.
attacks of inflammation are not at all characteristic of condyloma. It
must not be understood that there is absolute painlessness and freedom
from discomfort during the periods of quiescence. The parts involved
are always sensitive, and the encroachment of the tumors on the anus,
together with the infiltration and thickening of the integument and
subcutaneous cellular tissue, cause a constant feeling of fulness in the
rectum, with urging to stool, which act, from the distension of the sen-
sitive tissues, is always more or less painful.
Treatment. The treatment of external hæmorrhoids must be de-
termined by the stage of the disease. Acute cases can usually be
cured quite promptly and satisfactorily by remedies alone, or aided
by some soothing local application. When the tumors are large, I am
of the opinion that much benefit can be derived from opening them
and turning out the clot. The blood will be found coagulated, and
DISEASES OF THE ORGANS OF DIGESTION.
783
hence there will be little, if any, hæmorrhage. To many who, like
myself, have been reared in the strictest observance of the canons of
homoeopathic practice, this may seem objectionable teaching; but the
result of over twenty years' experience has been to lead me to very
much question the wisdom of allowing such cases to pass over into
a chronic state when a simple expedient will have the effect to pre-
vent such a catastrophe. A hæmorrhoidal tumor has a natural ten-
dency to rupture and subcutaneous extravasation of blood. The parts
in its neighborhood thereby become thickened and infiltrated, with
a predisposition to acute inflammatory action on slight provocation.
Now, if such a tumor is laid open early, there is a probability that
the vein will be obliterated, and thus a future tumor will become
almost impossible in that locality. Furthermore, should the case be
taken in hand sufficiently early, there will be no exudation into the
cellular tissue, and thus another prominent predisponent to future
trouble will be avoided. To say nothing of the speedy, almost imme-
diate, subsidence of pain, it seems to me that humanity, and a correct
knowledge of the natural history of the affection, would prompt the
intelligent practitioner to such a course. Even late in the case, the
effect of removing the coagulum, whether in the vein or cellular
tissue, can have no other effect than to place the patient in the best
position to escape future attacks. On the other hand, such treatment
may have the effect to produce a scar that may prove very trouble-
some. Therefore, when an incision seems to be demanded, it must be
made in the natural fold of the part.
Occasionally, remedies conjoined with warm and moist applica-
tions will so quickly subdue pain and inflammation that other treat-
ment is not required. Undoubtedly, such a method is to be preferred,
yet even then a coagulum will remain and continue as a menace to
future comfort. The rule should be, therefore, to give remedies if the
case is seen early, before there is much, if any, infiltration into the sur-
rounding parts, and to apply hot cloths or other soothing and emol-
lient dressings. Should relief be speedily attained, well and good. If,
however, the progress of the case is not arrested, or should the attack
be a second or a third, or again, should it be seen only after consider-
able exudation or extravasation have occurred, then by all means lay
open the tumor or tumors, turn out the coagula, and apply soft com-
presses wet with warm water into which a few drops of Hypericum
have been dropped. Should inflammation continue in the wound—
which the remedy indicated above usually prevents-Aconite, Bella-
donna or Rhus may be given according to indications.
In the chronic forms, where the tumors are large, cause much dis-
comfort, and are subject to frequent acute inflammations, I do not
believe remedies are of the least value. The tumors should be re-
moved with sharp scissors, including as much of the thickened integu-
784
A SYSTEM OF MEDICINE.
ment as can be spared, keeping in view the danger of troublesome
contracting scars.
Internal hæmorrhoids, from every point of view, are far more serious,
and constitute the form more frequently seen by the surgeon. They
are tumors, venous or arterial in character, sometimes both kinds of
vessels being present, formed above the sphincters, appearing exter-
nally when very large or when brought down by straining at stool.
The symptoms produced are as follows: In the early stages there is
some increased frequency in calls for stool, which is somewhat unsat-
isfactory from a feeling of incompleteness. Later, there are more or
less frequent hæmorrhages, sometimes occurring in connection with
the stool, and sometimes without. At times the hæmorrhage is quite
profuse, largely of venous blood; again, not very large in amount and
evidently arterial. When the hæmorrhages are frequent and severe,
there are constitutional signs of such loss in the blanched face, weak
and tremulous pulse, irritable heart, debility, and the ordinary symp-
toms of traumatic anæmia. There will also be more or less pain in
the loins, sometimes extending down the thighs, and in the case of
women, as H. Smith (Holmes' Surgery) says, who very often suffer
acutely, their sufferings are not unfrequently "referred to that prolific
storehouse of morbid phenomena, the womb." There will usually be
some considerable irritability of the bladder, often strangury or re-
tention of urine, and symptoms of disordered digestion are frequent
and pronounced. But these, while sufficiently severe and ominous,
are not at all the consequences of internal hæmorrhoids. As they in-
crease in size they often protrude at the anus, sometimes from walk-
ing or after standing for an unusual time, almost always at stool.
They excite spasmodic contraction of the sphincter, which causes in-
tense pain. At first they are easily replaced; after a time, however,
either from their increased size, the length of the pedicle which is
increased by the traction, or a partial inversion of the rectum from
the same cause, reposition becomes increasingly difficult, and reten-
tion a matter requiring constant care. They become strangulated for
longer periods, and as the constriction only becomes released by a
hæmorrhage, the effects on the patient soon become very serious
indeed. The symptoms I have given above represent the worst forms
of the disease, a form which many sufferers undoubtedly escape to
some extent. The differences, however, are in degree rather than in
kind.
A patient applying for relief from these symptoms presents signs of
rectal tumor, ulceration, or fissure, and it is manifestly essential to
arrive at a complete understanding of the case. This can only be had
by a thorough physical examination by means of a speculum. A
speculum should be used in all cases, even when pile tumors are
readily found at the anal orifice, for it has been shown by Mr. Smith
DISEASES OF THE ORGANS OF DIGESTION.
785
(1. c.) that it is not an uncommon occurrence to find two or three rows
of tumors, at distances varying from an inch to two inches from each
other, the upper rows not presenting sufficiently low down to be seen
without a speculum. Placing the patient in a recumbent posture, on
one side, with the knees well drawn up, the nates are separated, and
he is directed to strain slightly, as at stool. Usually, the tumors, or at
least the lower row, will protrude and appear sometimes as smooth,
shining, bluish masses, often like a bunch of grapes, or as red, single
tumors. On examination the blue masses are found to be composed
of dilated venous pouches, the mucous membrane covering them being
thickened and perhaps excoriated; the red tumors are found to be
largely composed of enlarged arterial twigs, sometimes the size being
considerable, varying from that of a cherry to a walnut, perhaps even
larger. The structure of the tumors is similar (if not identical) to
that of varix generally, even to the enlarged stigmata through which
the blood exudes. In other cases, the arterial, they resemble the vari-
cose aneurism.
On laying open a tumor, in the case of a vein, it will be found to be
partly filled with a coagulum and fibrous organization, its walls some-
what thickened, and the cellular tissue in the neighborhood infiltrated
with fibrous material. Coagula are also found in the arterial form,
but the bleeding is more active, and there is less surrounding infiltra-
tion.
There is still a third form of pile tumor, not pedunculated, as the
two former usually are, but sessile, sometimes scarcely presenting
characters of a tumor. These are villous or papillomatous growths,
not much elevated, bleeding very readily on touching or irritating
them, and usually constituting the upper rows when more than one
row is found. I have thought it possible that these villous tumors
might become pendulous and pedunculated, were time given them for
full development, as it has been surmised by some observers that the
pendulous masses, when arterial, originated in this form, and become
pedunculated by detachment at the base and elongation of the feeding
vessel from traction.
As symptoms associated with piles of the internal variety, we find
the integuments about the anus relaxed, sometimes disposed in pendu-
lous folds, and bathed in an offensive mucous discharge, sometimes quite
distinctly purulent. There is often much pruritus ani, in some cases asso-
ciated with an eczematous eruption which, joined to the irritation from
the discharge and the blood drying on the clothing, produces great dis-
tress from the resulting excoriation. The dragging of the hæmor-
rhoidal tumors, their frequent protrusion and strangulation, and the
atony of the rectal muscular fibres frequently induce more or less
prolapse of the rectum, the sufferings being thereby much increased.
Like external piles, those of the internal variety have periods of ex-
VOL. I.-50
786
A SYSTEM OF MEDICINE.
acerbation and amelioration. Some dietetic excess or error, an attack
of diarrhoea, or a constipation; an unusually long walk or other vio-
lent exercise; excessive coitus, or anything which would have the
effect to increase the amount of blood in the pelvic vessels, or to excite
unusual irritation, may result in inflammation and an acute attack.
Patients, however, soon learn to avoid that which brings them suffering,
but not seldom ignorant people, professional as well as lay, lead them
to promote bleeding as a means of relief. It is true that many urgent
symptoms are relieved by the haemorrhage, but the ultimate results.
are disastrous in the extreme. Not only do the symptoms of a general
character become greatly aggravated by the hæmorrhage, but the atonic
condition is also rendered worse, so that the transient relief is very
dearly purchased at the expense of much future suffering.
Treatment. I am strongly of the opinion that the best results in
the treatment of this variety are obtained from remedies. Operative.
measures of all kinds, ligature, excision, cautery and injections are to be
held in reserve for a very last resort. The objection to operative meas-
ures whereby the tumors are removed, is the danger of cicatricial con-
traction, with a possible stricture as a result, predisposing to some form
of intestinal obstruction. The objection to the injection of medici-
nal substances into the tumors is the danger of embolism, under the
most favorable circumstances forming a thrombus which, in the ma-
jority of cases, simply postpones a more formidable operation. Never-
theless, there are cases in which injections of carbolic acid, or some
other agent of similar properties, will produce a firm clot that subse-
quently becomes absorbed. In a considerable number of cases, some
writers assert a majority, the clot will remain unchanged, and furnish
the occasion for an acute inflammatory attack at a later date. The
tumors being of large size, the cause of much suffering, or the patient.
being much reduced in vigor, an operation of some kind seems to be
called for. Under other circumstances and conditions milder meas-
ures must be preferred. It does not enter into the plan of this work
to discuss these operations, nor their indications, at least not in detail.
It must be borne in mind that the ligature, or the removal of the
tumor with scissors or other cutting instruments, is not to be used in-
discriminately; each method has more or less exact indications, for
which the reader is referred to works on surgery.
The remedies which are found useful in hæmorrhoidal affections are
as follows: Esculus hip., Aloes, Arsenic, Belladonna, Calcarea carb., Carbo
veg., Dioscorea, Erigeron, Hamamelis, Lachesis, Muriatic acid, Nitric acid,
Nux vom., Phosphorus, Podophyllum, and Sulphur. In connection with
the indicated remedy, in acute cases, hot or cold applications (as
may be most comfortable to the patient) must not be neglected; the
patient must be kept as quiet as possible, and some attention paid to
the diet. In chronic cases, attention must be paid to keeping irritants
DISEASES OF THE ORGANS OF DIGESTION.
787
at a distance, and to avoid all acts which experience has taught the
patient may be productive of an acute attack.
Æsculus hip.—Mucous membrane of rectum very dry, producing a feeling as if
sticks were in it; constipation, with feeling as though a fold of mucous membrane
were obstructing the passage; fearful of straining, from sensation as though it would
cause prolapsus; aching, lameness, or shooting in back.
Aloes. This is one of the most useful remedies; at least in my hands it has pro-
duced many excellent results. The piles protrude like a bunch of grapes, with constant
bearing down in the rectum, and stools of a jelly-like substance; there may be no ac-
tive hæmorrhage, but at times it is severe. Diarrhoeic stools, with much flatulence, so
that the patient is in doubt whether it is stool or flatus that passes.
Arsenicum.-Piles with stitching pain when walking or sitting; not when at
stool; with burning pain; pains better from heat. Watery, excoriating diarrhoea, with
restlessness and great debility.
Belladonna.-Bleeding from piles, profuse, arterial; contraction of sphincters,
with puffiness and congestion of mucous membrane; great sensitiveness to touch, so
that the patient lies with the nates separated. Pain in the back as though it would
break.
Calcarea carb.-Protruding piles, painful when walking, better when sitting;
painful at stool. Irritability of anus causes all stools, hard or soft, to be painful. Much
milky mucus; offensive discharge.
Carbo veg.-Large bluish varices, bleeding freely; much flatulence and eructa-
tions of gas; colicky pains from incarcerated flatulence, relieved by eructation; much
offensive moisture, and viscid mucus about the perinæum and anus. Burning and sore-
ness of the anus.
Dioscorea.-Piles, like grapes, around the anus, not bleeding; slimy mucus in-
voluntarily discharged from the anus; hæmorrhoidal tumors of livid color, prolapsed,
with great pain.
Erigeron can.-Hæmorrhoids with great and frequent passive hæmorrhage;
burning around the anus, which feels torn.
Hamamelis.-Bleeding from piles, producing great exhaustion; out of propor-
tion to the amount of blood lost; particularly useful in large blue hæmorrhoids, where
the blood does not tend to coagulate, or does so very imperfectly.
Lachesis.-On coughing, a stitching pain upwards in the pile tumors; beating,
as if from little hammers in the anus. Blood dark, fluid, coagulates slowly or imper-
fectly.
Muriatic acid.-Sudden hæmorrhoidal attacks, particularly in children, with
protrusion of bluish piles, very sore, and so sensitive to contact that even a sheet is un-
comfortable. Prolapsus recti, or protrusion of piles when urinating.
Nitric acid.-Bright red, uncoagulated blood from the piles; particularly worse
in warm weather; the bleeding so profuse that the least motion causes faintness.
Tearing pain in the rectum at each stool; feeling as if the anus were full of splinters
or sharp pieces of glass.
Nux vom. This remedy has long enjoyed a reputation for the cure of piles, and
is oftener given empirically than any other. It is particularly useful when the rectum
feels spasmodically closed, with habitual constipation, especially if it alternates with di-
arrhoea. Bruised pain in the small of the back, making it difficult to rise quickly from
a sitting position.
Phosphorus.-Free hemorrhage from the rectum, flowing in a small steady
stream. Difficult passage of long, narrow, tough fæces.
Podophyllum.-Piles in connection with chronic diarrhoea, occurring mostly
in the early morning, preceded by pinching pains; stools light-colored and very
offensive. Prolapsus of rectum at almost every stool.
Sulphur.-This remedy divides the honors with Nux vomica among routine pre-
scribers. It is chiefly suitable for old chronic cases in which the piles are rarely pain-
ful. There is usually a chronic diarrhea, sudden urgency early in the morning.
Considerable blood passes with the stool, usually dark-colored, and there is some sore-
ness of the anus and bruised lameness of the back.
788
A SYSTEM OF MEDICINE.
PROLAPSUS RECTI.
Prolapsus of the rectum occurs in two forms, that of the mucous mem-
brane alone, and that in which the whole rectum, or rather all its
tissues, are found in the protruded portion. This latter form I prefer
to call procidentia. Prolapsus, to adopt the above classification, is per-
haps equally common at all periods of life, possibly, however, it may
be observed oftener among children. It is a protrusion of the mucous
folds lying nearest to the anus, transient or permanent. A normal
evacuation of the bowels is always accompanied by some protrusion
of the rectum, which, however, is withdrawn again on the completion
of the act. The loose connection between the muscular and mucous
layers of the rectum permits considerable mobility of the latter upon
deeper parts, and if from any cause the mucous tissue becomes
thickened and infiltrated, this already loose connection may become.
still more slight. Under these circumstances the protrusion, if fre-
quently repeated, gradually includes more and more of the loose
tissue, at the same time adding to the already existing congestion,
until an amount is finally prolapsed which can again be returned.
within the anus only with great difficulty. The first protrusion is
usually reduced without difficulty, but is often very painful; when
the accident is repeated, reduction becomes more and more difficult,
the irritable sphincter constricting it firmly, and producing much pain.
On examining such a protrusion, it is seen to be a conical projection,
red and smooth, covered with mucus, and with a sulcus or fissure.
around its base, as would be the case in intussusception of the rectum.
The opening of the cavity of the rectum is seen at the apex of the pro-
trusion. In cases in which the accident has been frequently repeated,
the mucous membrane is found thickened and hardened, somewhat
leathery, more or less eroded, and when the protrusion is reduced,
some of the folds are found to remain without the anus and to have
assumed the character of integument. As time goes on, unless a cure
is effected, the portions habitually without the sphincter become
larger and lose all the characters of mucous tissue.
Procidentia recti is almost entirely, I believe, an accident of adult
life, possibly more common among those past middle life. It has been
observed, however, at all ages. It seems to be more common among
women. Probably, could the early history of such cases be secured,
it would be found that they commenced as a simple prolapse of the
mucous tissue; but, when they come to the surgeon as procidentia,
the protrusion is found to be composed of all the layers, mucous, mus-
cular and fibrous. In many cases the protrusion is not constant, but
in the majority more or less of the bowel is habitually without the
anus. We find the mucous membrane thickened, hard and leathery,
either dry (which is the customary state), or covered with mucus more
or less purulent. It may be so voluminous that it becomes an abso-
DISEASES OF THE ORGANS OF DIGESTION.
789
lute impediment to locomotion. The proximity of the bladder, ure-
thra, and prostate gland in men, and the sexual apparatus in women,
entails usually some associated disturbance in these organs. Particu-
larly do we find vesical irritation, strangury, retention of urine, or
enuresis.
The causes of prolapsus and procidentia are similar, in fact the same,
if we esteem the latter to be an advanced stage of the former, of which
there can be very little question. The first cause must be something
productive of atony, either operating through local causes or generally.
Thus, any condition that induces general muscular atony must have
some causative influence on the production of prolapsus recti, at least
predispose to it. Violent diarrhoea or dysentery has the effect to in-
duce atony of the intestinal muscular elements, and the straining and
tenesmus associated with these disorders may cause prolapse. Thus,
enlarged prostate, urethral stricture, or stone in the bladder, from the
straining required to empty the bladder, are often prominent exciting
causes. Hæmorrhoids play a very important part in this particular,
both from the traction exerted on the mucous coat, the hæmorrhages,
and the frequent straining at stool. So also tumors of the rectum
may by traction produce an inversion or invagination. The peculiar
laxity of the mucous coat is always to be considered among the com-
mon predisposing causes; when we have muscular atony, and some
morbid condition, near or remote, that excites frequent contraction of
the abdominal walls, as at stool or urination, a chain of causes can
easily be made out.
Treatment.—In the severer forms of procidentia recti, where the
mucous coat and, indeed, all the tissues are extensively and perma-
nently altered, and where the portion habitually without the sphinc-
ters is of large size, I do not think remedies can be of the least avail.
In the minor degrees, more particularly when the condition is still
acute or recent, remedies have produced many remarkable cures. In
fact, it is doubtful whether any other measures are ever called for in
such cases. A complete symptomatology of the remedies that might
be indicated would take up too much space, the condition being as-
sociated so closely with diarrhoea, dysentery and hæmorrhoids.
The remedies oftener employed are not many in number, and a se-
lection should not be a matter of much difficulty in ordinary cases.
Still, reliance must not be placed on them alone to the exclusion of
certain mechanical measures which are of the very first importance.
Reduction or reposition of the protruded gut is the first indication,
if it is strangulated. The protrusion is to be well lubricated with fresh
lard or some other bland and unctuous material; joining the tips
of the fingers of the right hand together, press firmly on the centre
of the projection, at the same time separating the nates as much as
possible with the other hand. It is very rarely that there will be a
790
A SYSTEM OF MEDICINE.
failure to replace the intestine. In the case of procidentia, particularly
when the protrusion is large and the tissues have undergone much
change, such treatment is useless; the altered tissues would constitute
a foreign body in the rectum, and could not be retained.
Having reduced the prolapsus, the next step is its retention within
the pelvis. In aggravated cases bandages, or some form of mechanical
support, may be needed, but in most instances the bowel will remain
in place until some unusual exertion, some effort at defecation or mic-
turition, reproduces the prolapsus. Hence, the patient must be cau-
tioned in these particulars, and we must see that he thoroughly under-
stands the necessities of the case.
In an acute case, one that has occurred for the first time, and with
some strangulation, Arnica should be given, or applied locally, or
both, for some hours. By attention to the bowels, correcting any di-
arrhoea, or the like, that may be present, it is not often that the acci-
dent will be repeated. In cases in which the accident is of somewhat
frequent occurrence, the chief indication, so far as mechanical meas-
ures are concerned, is to secure retention, if possible, and to avoid, ast
far as practicable, any occasion that may reproduce the displacement.
The remedies oftener useful are as follows:
Belladonna.-Where there is constriction of the prolapsed rectum, the parts
being hot, red, and swollen, particularly if the sphincter is strongly contracted and
the parts are intolerant of the lightest touch.
Hamamelis.-When the prolapsus occurs in connection with varices of the
rectum, from which there is copious hæmorrhage of fluid dark blood, with little ten-
dency to coagulation.
Ignatia. This remedy is useful for children when prolapsus occurs with every
stool, hard or soft, with or without straining. Stitches up the rectum, and an itching
as from ascarides in the anus.
Mercurius cor.-Prolapsus, with dysentery, in which there is almost con-
stant tenesmus during and for some time after stool. The stools are frequent, small,
bloody and mucous.
Muriatic acid.-When urinating, discharge of thin, watery stool, with pro-
lapsus recti. Prolapsus, with (or from) hæmorrhoidal tumors.
Nux vom.-Diarrhoea, alternating with constipation, in which there is prolapsus
with the stool, although between the stools the anus seems spasmodically contracted.
Podophyllum.-Prolapsus with almost every stool; particularly when the
stools are light-colored, very offensive, preceded by pinching, colicky pains, and mostly
early in the morning.
Sulphur.-Habitual constipation, with frequent urging to stool; ineffectual,
during which the retum becomes prolapsed. Prolapsus occurs under reverse circum-
stances, with the characteristic morning diarrhoea.
The treatment of procidentia is purely surgical. Many cases require
excision of the rectum or some equally formidable operation, and the
reader is, therefore, referred to works on general surgery.
ULCER AND FISSURE OF THE RECTUM AND ANUS.
The lower portion of the rectum, just within the sphincters, is dis-
posed in folds which peculiarly dispose it to retain portions of fæces
DISEASES OF THE ORGANS OF DIGESTION.
791
or foreign material contained in the stool, although these folds are
smoothed out during the passage of the stool. A portion becoming
lodged, usually close down to the sphincter, is firmly held in the crease
or fold, and soon sets up an inflammation, sometimes a preceding
abrasion which forms a superficial ulcer. On partially opening the anus,
this has the appearance of a slit or fissure, but on introducing a specu-
lum, whereby the parts are put upon the stretch, it is seen to be a
shallow ulcer, round or oval in form, about or of an inch in diam-
eter. On the opposite side of the rectum will often be found a papil-
lomatous projection, which seems to fit into the ulcer and assists in
keeping up the irritation. My opinion is that the papillomatous
growth is often a cause of the ulcer, and not secondary upon it. How-
ever formed, these sores are not disposed to heal spontaneously, and
are productive of the most exquisite suffering.
The pain is rarely experienced during the stool; it usually comes
on immediately afterwards, sometimes even after an hour. It is then
exceedingly acute, completely prostrating the sufferer. So severe are
the pains that patients often postpone defecation to the longest possi-
ble intervals, sometimes even denying themselves food in the vain
hope to avoid a movement of the bowels. Cases are even reported
where chloroform was taken to the closet whenever a motion of the
bowels could be no longer delayed. The sphincter soon becomes ex-
ceedingly irritable, so that it will not tolerate contact of any kind,
feeling like a hard, solid ring under the integument. The bladder be-
comes also sympathetically affected, as does the vaginal sphincter,
resulting, in the latter case, in vaginismus. It is this extreme sensi-
tiveness which causes the frequent error of diagnosticating a fissure,
as dilatation of the anus is impossible, and the shape of the ulcer
cannot be made out.
These irritable ulcers occur for the most part about the period of
middle life, and oftener among women. When fully formed, or chronic,
the irritability is so extreme that a satisfactory examination cannot be
made without anesthesia. The contraction of the sphincter being so
violent, there is a constant danger of foreign material being retained
from the fæces, and the distension to which the parts are subjected at
each act of defecation keeps the sensitive sore from healing. From
perfectly natural causes, therefore, such an ulcer must prove very in-
tractable.
Treatment. The conditions of the part are such, anatomically
considered, that it would seem almost impossible to produce a cure
without, in some way, placing the parts in a different relation. This
is to be done by paralyzing the sphincter, and thus removing one of
the chief obstacles to a cure. As a matter of fact, an effectual paralysis
of the sphincter often produces a cure without any other treatment
whatever. The most convenient method is that of Pattison, as fol-
792
A SYSTEM OF MEDICINE.
lows: First anesthetize the patient, and then, lubricating both thumbs,
introduce them into the anus, back to back, until the muscle is felt to
be included within their grasp. Now separate the thumbs, with a
sudden force, drawing the margins of the anus outwards until they
reach the tuber ischii on each side. This usually, to some extent,
lacerates the floor of the ulcer. If it fails to do so, it is best to incise
it in the direction of the rectal fold, not carrying the knife deeply,
only sufficient to cut through the mucous layer. In very many,
probably a large majority, of cases, ulcers so treated will heal very
quickly, all symptoms disappearing by the time the irritability of the
sphincter is destroyed. I think the success of the operation depends
upon a rupture or laceration of the floor of the ulcer; simple paralysis
of the sphincter will not prove sufficient. Separate the thumbs, there-
fore, with a sudden force, and if laceration does not occur, incise the
floor of the ulcer with the lancet.
Remedies should be used, however, to hasten healing, Calendula taking
the first rank. Should the ulcer fail to close from this treatment, it
should be repeated, and some remedy given that would be indicated
by the symptoms of the ulcer as they occurred prior to the stretching
of the sphincter. Probably Arsenicum, Belladonna, Pæonia, Lycopodium,
Mercurius, Nitric acid, Rhus, Silicea or Sulphur, one or the other, would
be found curative.
IRRITABLE SPHINCTER.
In hysterical persons, or in those unusually sensitive to pain, there is
sometimes found a condition of irritability of the sphincter ani which
very closely resembles ulcer as described above. There is great pain
on the passage of stool, but it is during the passage, as well as after-
wards, thus differing from ulcer. Moreover, it is more of an aching
or constricting feeling, somewhat as though the parts had been con-
tused. On attempting a physical examination, the sphincter will
violently contract, as occurs in the case of ulcer, but there is not that
extreme sensitiveness which occurs in the former complaint. The
finger having passed the sphincter, the muscle is felt like a tight cord.
and, in old cases, much hypertrophied. There is no sensitiveness in
the lower portions of the rectum, the pain being entirely in the sphinc-
ter muscle. On attempting to evacuate the bowels, the sphincter be-
comes spasmodically contracted, the anus being drawn inwards, and
after the act is accomplished there is a feeling of incompleteness of the
The bowels are
evacuation from the continued muscular spasms.
usually constipated, which condition adds to the painfulness of the
act, and near parts soon become sympathetically affected. The aching
which persists after a movement of the bowels is very severe, and for
some time prevents sitting, or even walking, with any comfort.
Treatment. Remedies suggested by the general condition must
DISEASES OF THE ORGANS OF DIGESTION.
793
be given the first place in these affections, although in aggravated
chronic cases a division, partial or complete, of the sphincter may be
needed. The remedy oftener called for is Belladonna, although Cuprum,
Platina, and Plumbum are prominently indicated. The affection being
for the most part a concomitant of constipation, special indications for
these, and other remedies, may be found in the article on that subject.
TUMORS OF THE RECTUM.
Tumors of various kinds occur in the rectum, and yet remembering
the frequent irritation to which the functional activity of the part gives
rise, it is remarkable that they are not observed oftener and in greater
variety. The usual form is the polypoid, either follicular or fibrous,
and a villous tumor which, to all intents and purposes, may be con-
sidered a pile. The symptoms, ætiology, and pathology are not at all
different from tumors of the same kind in other situations, at least so
far as the growth itself is concerned; other symptoms peculiar to the
region, on the other hand, have no special significance as indicating at
tumor. There is a feeling of fulness in the rectum, more or less urg-
ing, and unsatisfactory defecation, but the same symptoms are pro-
duced by enlarged prostate or hæmorrhoids. There may be violent
bleeding or pain from a villous tumor, but hæmorrhoids, ulceration,
or irritable sphincter furnish similar indications. Sometimes, when
the tumors are pedunculated, the morbid growth may appear at the
anus. Even then it may be mistaken for a hæmorrhoidal protrusion.
As a matter of fact, to all intents and purposes the growth may be
considered hæmorrhoidal, and treated as such. This similarity in
symptoms of many different morbid conditions adds emphasis to
what was said in an earlier paragraph, viz., that an examination must
be thorough, and not held to be complete until a speculum has been
used, and the tumor brought into actual view.
The pathology and histology of these tumors being identical with
the same growths in other regions of the body, the treatment is like-
wise to be the same. They should be removed as soon as detected, and
care had to include enough of the base to reduce the chances of re-
currence, without leaving a wound likely to be followed by serious.
cicatricial constriction.
FISTULA IN ANO.
Anal or rectal fistula, like fistulæ generally, are the result of abscess.
An abscess forms outside of the rectal tissues, and burrowing through
the loose connective tissue and between the muscles, points in the
perinæum or near the anus; from some cause the track does not close,
but remains as a blind external fistula. In another case, a foreign par-
ticle lodges in one of the rectal folds of mucous membrane, sets up
acute inflammation, with ulcerative perforation and abscess, as in the
794
A SYSTEM OF MEDICINE.
former instance, leaving a track communicating with the interior of
the intestine at one end and the integument at the other, forming a
complete fistula. There is still a third form, in which the process com-
mences as in the last variety, but is not continued to the tegumentary
surface, thus leaving but one opening, that into (or from) the rectum.
This is called a blind internal fistula, and is probably more common
than is generally supposed.
The commoner site of the rectal opening is just within the sphincters,
where the suddenly narrowed canal affords favorable lodgement for
foreign material, and the longitudinal folds of mucous membrane
afford convenient receptacles for retention. The anal or perinæal
opening is usually within some of the folds of integument surround-
ing the anus, or the mucous folds within it. Short as the distance, in
a direct line, is between these two openings, the fistulous track may be
quite long, owing to numerous curves and flexures in its course as it
is directed between the various bundles of muscular fibres, as the
general course in the direction of least resistance. The fistula once
formed, it is kept open by the passage of gas, fæcal matter, and the
various motions to which the parts are subjected, and soon it becomes
lined with a firm pyogenic membrane, which, in time, becomes organ-
ized and permanent.
The symptoms at first are not very striking after the abscess has
ceased to be active, and for a long time may escape the attention of
the sufferer. After a time, there is noticed an involuntary escape of
flatus, occurring at inopportune moments, and the clothing is found
soiled with fecal matter and pus, notwithstanding the utmost care and
cleanliness. Medical advice is then sought, and examination will at
once reveal the source and nature of the trouble. Should the opening
be on the integument, it will appear as a little florid pimple-like eleva-
tion, similar to what is observed in necrosis, which is found to consti-
tute a flap-like covering for the fistula. If the opening is within the
mucous or cutaneous folds of the anus, the part must be exposed to a
good light, and, passing the finger into the anus, we must make pres-
sure at different parts of it, pressing outwards at the same time, by
which means a drop of pus, mucus, or some particle from the bowel
will be forced out, thus enabling us to locate the orifice. Having
found the opening, with the forefinger of one hand within the sphinc-
ters, pass a delicate flexible metal probe into the external opening,
rotating it between the thumb and finger, and gently pass it along the
fistula. Should the fistula be complete, the end of the probe can be
felt by the finger in the rectum; if not complete, it can be felt im-
pinging on the mucous membrane. In the latter case the probe
should be withdrawn a little, and passed onward in various directions,
to be sure that what had been thought the bottom of a blind fistula
is not an angle of a complete one. Should it appear, after faithful
DISEASES OF THE ORGANS OF DIGESTION.
795
effort, that the probe will go no further, a blind fistula may be diagnos-
ticated.
The consequences of anal fistula are not of light moment. To be sure,
the constant mortification to which the sufferer is subjected renders
the condition one of gravity; but it is productive of serious physical
consequences as well. Apart from the irritation of the parts so con-
stantly bathed in the secretions from the fistula, and the discomfort
in walking and sitting, whether as cause, effect, or only coincidence,
there certainly seems to be a close relationship between pulmonary
tuberculosis and this condition. Such relationship is denied by many
good authorities, but my own experience would go to prove the fact of
such relationship. In looking over my case-book I can find few records
of anal fistula in which some reference to tuberculosis does not appear.
As the mass of authority seems to be arrayed against this assertion, my
cases may be considered mere coincidences.
Treatment. The treatment of fistulæ is based entirely upon the
stage and the kind. Thus, an old fistula, with a firmly organized
pyogenic membrane, may be considered entirely incurable so far as
remedies administered internally are concerned. A blind internal
fistula, one with no cutaneous opening, is incurable by any means
until it is converted into a complete one. In all forms there are two
cardinal indications: the sphincters must be paralyzed during the con-
tinuance of treatment, or through a considerable portion of this period,
and some effort must be made to prevent the passage of the contents
of the bowel into the canal. The paralysis of the sphincter can be
secured by stretching it by Pattison's method, given in a preceding
paragraph; the prevention of the entrance of foreign material may be
secured by a rectal plug or obturator of hard rubber or even wood.
The pyogenic membrane must be destroyed as a preliminary to any
treatment. If it is a recent case, and the lining membrane is loosely
organized, it may be possible to secure cicatrization by simply para-
lyzing the sphincter and closing the rectal orifice. Under other cir-
cumstances the membrane must be destroyed, either by caustic appli-
cations, scarification, or, in short and straight tracks, by dissecting it
out. In old cases, where the pyogenic lining becomes almost cartilagi-
nous, it may become of embarrassment as to its effectual disposition.
Such cases are purely surgical.
Assuming a case to be of a sub-acute character, with a loosely-organ-
ized lining membrane, laceration with the probe may be sufficient
treatment; the sphincter is then stretched, the track washed out by
means of a small syringe, and the obturator or plug inserted. Daily
for a time, say for three or four days, the probe is to be passed, injec-
tions used, and the sphincter stretched, if need be. Ordinarily, there
will be immediate improvement, particularly if Calendula is used in
the water thrown up from the syringe. Perhaps Causticum, or some
796
A SYSTEM OF MEDICINE.
other remedy indicated by the general condition of the patient, may
be employed, but the chief reliance is to be placed on keeping the
parts quiet by paralyzing the sphincter, and upon the closure of the
rectal orifice. Should failure result, after an interval of a week or
longer, repeat the treatment, but insert a soft rubber tube, or any soft
material which the track will accommodate, and thus promote healing
from the bottom. Should the case still remain uncured, proceed as in
the case of the chronic form.
Chronic cases, with a dense, firm lining membrane, can rarely be
cured without converting the fistula into an open wound. There are
two methods, chiefly, by which this may be accomplished. The most
efficacious, least painful, and altogether most satisfactory way is to
divide the tissues with the knife, on a director, provided the tissues in-
cluded are not of a character that such division would produce serious.
consequences. Thus vessels of size, or important muscles, should not
be divided; the sphincter itself, if it can be avoided, should not be
completely divided. If circumstances forbid the use of the knife, a
ligature may be employed, passing it through by means of a blunt
needle, and tying it tightly. Silk or the elastic ligature of Dittel may
be used, the former being preferred. I prefer the silk, as it causes less
pain than the elastic ligature and is equally efficacious. Ligature
generally, however, is a painful mode of treatment, and not to be pre-
ferred to the knife unless circumstances forbid the latter.
I do not mention remedies in this connection, for two reasons.
The first is that there does not seem to be any field for them, the con-
tinuance of the fistula being entirely dependent upon mechanical
causes; and secondly, if the fistula is a part of a general or systemic
morbid action, the remedy that would be indicated might rationally
be supposed to include the fistula.
STRICTURE OF THE RECTUM.
Strictures of the rectum, of which the physical characters are suffi-
ciently described by the term, proceed from the same class of causes
which produce stricture in other parts of the intestinal canal. Per-
haps the function of the rectum peculiarly predisposes it to injuries.
which may result in this way, but the fact remains that from some
cause strictures oftener occur in this portion of the intestinal canal
than in any other. The location of the stricture is usually at the
lower portion, about an inch or an inch and a half from the anus;
sometimes it is found higher up, even at the commencement of the
rectum. Thus Curling (Reynolds's Practice of Medicine, iii., p. 269)
says: "In twenty-eight cases I found the stricture at 'one inch and a
half or two inches from the anus' in-twenty-one; in two it was nearer
the anus:; and in five at a greater distance. In three of the latter the
DISEASES OF THE ORGANS OF DIGESTION.
797
stricture was at the point where the sigmoid flexure terminates in the
rectum. In two instances I have met with a double stricture."
The causes of stricture are either inflammatory changes, usually of
a chronic form, or traumatism. Occurring, when non-traumatic, in
those who are of constipated habit, the constant irritation resulting
from hard stools and from long retention of hardened fæces sufficiently
accounts for the thickened and chronically inflamed state of the
mucous membrane. Some narrowing having thus been produced,
lodgement of portions of fæcal matter occurs, ulceration or fistula fre-
quently resulting, intensifying the original inflammation and increas-
ing the stricture at the same time. The increasing stricture predisposes
to pouching or sacculation of the intestine, and when it occurs suffi-
ciently high up, invagination, volvulus, or other forms of obstruction.
may occur.
Should there be ulceration without a preceding inflammation, that
is, without a stricture, the cicatrization of the ulcer may result in con-
striction, one that is progressive from the contracting property of all
forms of scars, but which in this region is more rapidly productive of
a major degree of the trouble from the inflammation due to the lodge-
ment of foreign material. The same consequences follow traumatism.
Traumatic lesions are common, inflicted in many ways. The frequent
or habitual use of enemas or suppositories are the commoner forms;
the passage of hard, angular, or sharp foreign material through the
intestine may lacerate the mucous coat or become lodged in some of
the folds or rugæ; or injury may be received from without, as gun-
shot or stab wounds. Stricture may arise from other causes, however,
but so exceptionally that they have rarely received any attention from
writers or teachers. Thus, tumors may cause compression from
encroaching on the bowel from without; tumors growing within the
rectum may have the same effect; prolapsus, from the redundancy of
the mucous membrane causing, or caused by, this condition; and many
other forms of morbid action that have the effect to thicken the
mucous lining or make traction upon the bowel or any of its coats.
However produced, the symptoms are very obscure and rarely
recognized until the affection becomes serious. Occurring in persons
of constipated habit, the gradual increase of constipation does not at
first attract attention. Later, however, there is much pain, usually of
a burning character, coming on after defecation, not as severe as occurs
in ulceration, yet sufficiently so to cause a suspicion of that condition.
If examination is now made, the true state of affairs may be discov-
ered, unless the constriction is so high up that it cannot be easily
reached with the finger. Later, there is a constant discharge of brown
sero-mucus, staining the linen, and causing an unpleasant fæcal odor
about the person; there are occasional attacks, of increasing frequency,
of dysenteric diarrhoea, largely of the explosive type, alternating with
798
A SYSTEM OF MEDICINE.
obstinate constipation. The stools, late in the case, become bloody,
more or less purulent, and small in amount; there is almost constant
urging to evacuate the bowels, the straining incident thereto increasing
the stricture and precipitating many of the late graver symptoms.
Late in the case, from the irritated and inflamed condition of the sur-
faces, the stools are very painful, the sensation often being likened to
that of boiling hot water. Abscesses, fistula, excoriation of the anus.
and perinæum, together with hæmorrhoids or villous tumors, fre-
quently complicate the case and render the sufferings of a very serious
character.
Treatment.—The treatment of stricture is based upon three indi-
cations: to correct the constipated habit; to reduce the inflammation
and its attendant induration; and to remove the stricture, at least to
an extent sufficient to permit the passage of an ordinarily soft stool.
To meet the first indication, remedies must be used as already laid
down in its proper place-constipation. It must not be forgotten, how-
ever, that the diet must be of a character to favor soft stool, and every
precaution must be taken to avoid the accumulation of feces in the
rectum. These measures have already received attention in a pre-
vious chapter. The inflammation and its consequent induration will
usually disappear together with the constipation. At this time, there-
fore, we have chiefly to do with the stricture and the means for its
disposal. In fact, it will rarely occur that the constipation can be
relieved, at least materially, until the stricture is improved, as this
condition acts as a mechanical obstruction to the passage of the fæces.
Furthermore, if treatment is undertaken late in the case, it will be
remembered that diarrhoea is a more prominent symptom.
The stricture having been located, we have a choice of methods for
its relief. In examining a case of suspected stricture, if the obstruc-
tion occurs low down and can be felt by the finger, no embarrassment
will ordinarily exist. If, on the contrary, the obstruction is high up,
there may be some difficulty. For purposes of diagnosis the most.
convenient instrument is the hand. Under an anesthetic the hand
can be passed up the rectum as far as the colon; but this should not
be attempted if the hand is large, or there is much acute inflamma-
tion or ulceration about the anus. If for any of these reasons it is
unadvisable to use the hand, and a single finger cannot reach the
obstruction, the rectal sounds, olive pointed, made on the principle of
Otis's bougies a boulè, should be used.
The stricture being located, divulsion, incision, dilatation, or elec-
trolysis may be practiced. These operations are all of the major class,
and reference is to be had to works on surgery for details, but the gen-
eral principles, at least as relating to selection of the method, may be
given at this time.
In general terms, when a stricture is of large calibre but firm, divul-
DISEASES OF THE ORGANS OF DIGESTION.
799
sion may be practiced. When cicatricial and of some degree of tight-
ness, incision. When very small, tight, and cicatricial, electrolysis.
Under all circumstances dilatation with graduated bougies must fol-
low either of these operations, particularly when the structure is cica-
tricial, and it must be persisted in until there is no disposition to a
return of the trouble. Silicea must also be used, I think not lower
than the 30th attenuation, from its well-known effects on scar tissue.
Incision or divulsion must not be hastily undertaken nor performed
without due precaution, as rupture of the intestine may easily occur,
an accident that might give rise to the most dangerous symptoms.
CANCER OF THE RECTUM.
Carcinoma of the rectum presents no symptoms that differ in any
respect from cancer elsewhere. Probably the three principal forms of
the disease occur in the same order of frequency-viz., scirrhous, en-
cephaloid, and colloid-in which they occur in other regions. From
the fact that the anus is an orifice partly composed of mucous tissue
and partly cutaneous, as well as a part which is very frequently ex-
posed to injury, both from forces operating from without and from
hard stools from within, carcinoma is quite a common occurrence.
The early symptoms of cancer are not at all pathognomonie; they are
common to many anal and rectal diseases, spasm of the sphincter,
ulceration and fissure, piles, stricture, etc., and may not attract the
attention of either surgeon or patient sufficiently early to permit
prompt treatment at a time and in a stage when there may be some
reasonable hope of relief or even cure. The case generally falls under
medical notice when far advanced, and when the only treatment avail-
able is purely palliative.
The disease usually commences just within the sphincters, at the
point where most rectal diseases originate, extending as a rule up-
wards and downwards simultaneously. From the loose texture of
the tissues of the part, particularly the loose connection between the
mucous membrane and the muscular coat, the absence of resistance
in almost every direction, and the constant irritation of the part from
the performance of its function, the development of the disease is
unusually rapid. The passage becomes rapidly contracted, sometimes
so much so that even a small probe cannot be passed, and from the
tendency of scirrhus to draw into itself near-lying parts, the passage
often becomes impervious, thus adding the sufferings attendant upon
retention of stool to those of the cancerous disease. Should the form
of disease be encephaloid or colloid, this tendency to contraction does
not always appear; on the contrary, there may be sloughing of large
masses, or the texture may be so friable and loose that no resistance
to stool exists. Furthermore, sloughing may establish large vaginal,
vesical, or perinæal fistula. Whether there is contraction or slough-
800
4.
A SYSTEM OF MEDICINE.
ing, one thing is quite noticeable and of almost constant occurrence:
the sphincters are soon rendered powerless, either from inclusion in
the cancerous disease or from the destruction of the nerves, so that the
retentive power of the anus is early lost. This causes incontinence of
fæces and involuntary stools, and later in the case, when the disease
is well advanced, the discharges flow out over the clothing or person
precisely as though through a metal tube.
The disease, as is the case with carcinoma generally, is peculiar to
the middle periods of life, and is often observed among women.
It
has been seen in children or young people, but not frequently. Oc-
casionally it has occurred as a secondary deposit, either from a pri-
mary disease higher up in the intestinal canal or even in other parts
outside of the digestive track. As is the rule in cancer, scirrhus is
generally primary, while colloid and encephaloid are as commonly
secondary.
In the early stages, as already noted, a diagnosis is not easily made;
the symptoms so closely resemble other non-malignant rectal diseases
that unless cancer exists in some other parts of the body no suspicion.
of the true state of affairs would be excited by the symptoms. When
the constipation becomes an almost complete retention of stool, and
the anus or perinæum becomes full and tumefied, above all when the
lancinating pains of carcinoma appear, the patient may apply for
relief. An examination in a comparatively early stage may find not
external symptoms. On passing the finger into the rectum, if the dis-
ease is situated low down, the cartilaginous constriction, feeling ast
hard and unyielding as gristle, will give a hint as to the condition.
Later there will be an equally cartilaginous feeling of the walls of the
rectum generally, which also become nodular; the nodules later pro-
ject from the anus, are hard, sometimes elastic, and have a tendency,
particularly in encephaloid, to bleed on being handled. The patient
soon becomes cachectic when this stage is reached, and there can be
little question of the nature of the case.
The prognosis is, of course, unfavorable in all stages and under
almost all circumstances. The disease having made sufficient prog-
ress to attract the attention of the surgeon, it is nearly always so far
advanced that even an operation can rarely, if ever, either save or pro-
long life.
Carcinoma generally may always be considered an emi-
nently dangerous and fatal disease, and in no other part of the body,
unless it be the pharynx and œsophagus, is it as rapidly fatal or cer-
tainly irremediable as in the rectum.
Treatment. In very early stages, or even later, should the dis-
ease be primary and the lymphatics not extensively implicated, ex-
cision of the rectum may cure. The conditions favorable to success,
however, very rarely appear, and yet early incision may not only pro-
long life, but render it more endurable. Other treatment is valueless;
DISEASES OF THE ORGANS OF DIGESTION.
801
I cannot find a well authenticated report of a cure by other means.
The treatment, therefore, as might be supposed, is purely palliative,
this being one of the cases in which humanity demands the employ-
ment of opiates to allay pain. Certain effects from remedies are never-
theless obtainable as a mitigation of some of the sufferings; possibly,
as is strenuously held by some, a cure may be secured in exceptional
instances. I have never been able to secure such results, and am,
therefore, naturally skeptical. The following medicines are credited
with having cured cancer: Arsenicum, Aurum met., Carbo anim., Conium,
Condurango, Hydrastis, Kreasotum, Lapis alb., and Mezereum.
ANAL TUMORS.
Tumors about the anus, in sufficiently close relation with the part
to be classified as above, are exceedingly common. With the excep-
tion of carcinoma, which usually extends to the anus from the rectum,
these tumors are nearly all tegumentary. Condyloma, warts, and
similar growths are quite common and present no peculiar features,
nor do they differ in any particular from similar growths elsewhere.
They are often found in persons of dirty habits, and not seldom are
connected with some form of venereal disease. When close to the
verge of the anus, they may be mistaken for hæmorrhoids, but the ab-
sence of attacks of acute inflammation and the history of their devel-
opment will usually prevent any such mistake. Fibrous tumors have
occasionally been observed, not of large size ordinarily, and usually
become pedunculated. I have seen two or three cases of fatty tumor,
also pedunculated. The common forms, however, are tegumentary
growths.
Treatment. The treatment of these tumors is the same as for tu-
mors in general, i. e., prompt removal. Warts and condylomata may
be cured with Thuja, Nitric acid, Calcarea, or Sulphur, but failure will
likely result unless particular attention to cleanliness is secured.
PRURIGO ANI.
Pruritis of the anus is an itching of the anus and perinæum, some-
times extending to the insides of the thighs and near parts, a very
common accompaniment of many morbid affections. It may be as-
sociated with hæmorrhoids, or other rectal diseases, or with diseases of
the uterus, bladder, or vagina; it may be caused by ascarides, or other
intestinal parasites, or arise without any recognizable cause, being a
purely unaccountable local hyperæsthesia. From whatever cause, it
may become a truly distressing complaint, robbing the sufferer of
sleep, and even rendering his days a torment. In the milder forms it
appears only at night, after going to bed, when sleep is prevented
for an hour or two. Rubbing or scratching will only afford momen-
VOL. I.-51
802
A SYSTEM OF MEDICINE.
tary relief, in the end greatly aggravating the sufferings. The itching
is so distressing that it is only by a strong effort of the will that scratch-
ing can be avoided, and very often those who can restrain the impulse
while awake, yield to it during sleep. The parts then become excori-
ated, dry, and leathery, forming cracks or even ulcers by breaking of
the thin, brittle epithelium. Sometimes there is an herpetic eruption
developed, when the itching and irritation are constant day and night,
sometimes so severe that the patient has no comfort sleeping or waking.
The scrotum, or the fold between the labia and thigh, becomes sore and
excoriated, often exuding an unpleasant moisture.
The condition must usually be looked upon as a pure neurosis, but
there are often some habits of the individual which seem to hold some
causative relation. In the absence of any recognizable near lesion, in-
quire into the habits of living. Some have observed that when ac-
tively engaged in absorbing occupations they cease to be annoyed;
others, that tobacco or alcoholic stimulants aggravate the sufferings;
others, that particular articles of food or drink increase the severity of
the symptoms. While little or nothing as to exact causation may be
learned in this way, useful hints may be obtained as to management.
Treatment. The removal of any cause that may be discover-
able is a common sense procedure. It has appeared, however, that
such causes are not at all times discoverable. Cleanliness must be en-
joined, and as cold water sometimes aggravates the trouble, warm ab-
lutions will be prescribed; should warm water cause aggravation, cold
must be preferred. The temperature of the water must depend en-
tirely upon the comfort of the patient. The bowels and bladder must
be looked to, and every care taken to secure a proper performance of
all the bodily functions. Proper medication is of the first importance.
The list from which the selection is to be made is very long, and some-
times, from the similarity of the local symptoms, the general condition
and minute constitutional peculiarities must be considered. For this
reason it is exceedingly difficult to give indications for all the reme-
dies which may be useful; my own rule has been to rely very largely
upon the periods and conditions of aggravation and amelioration.
The list from which I have oftener made a selection is as follows:
Alumina, Ammon. carb., Calcarea, Carbo veg., Causticum, Ignatia, Lyco-
podium, Nitric acid, Petroleum, Sepia, Sulphur. As an empirical prescrip-
tion some physicians seem to have had remarkable success with the
local application of Belladonna, mostly the cerate. Some others find
some oleaginous application helpful, as Vaseline, not omitting the
appropriate remedy. The special indications for the remedies men-
tioned are as follows:
Alumina.—Feeling of constriction of anus and rectum, with albuminons, stringy
discharge; difficult evacuation of bowels, whether stools are hard or soft. Worse on
alternate days, in the afternoon; when talking.
DISEASES OF THE ORGANS OF DIGESTION.
803
Ammonium carb.-Hard, knotty stools; worse in the open air, from cold,
from talking or hearing others. Better from warmth and in dry weather.
Calcarea carb.-Stools either hard or loose, white, and milky; fermented
stools. Sensation of dryness and coldness about the part. Worse from cold and damp
air; from cold water, after mental exertion, and on awaking.
Carbo veg.-Burning at the anus, with soreness of the perinæum, and oozing of
moisture. Worse in the open air, when warm in bed, from poultices, and from pressure
(or contact ?).
Causticum.-Pulsation in the anus and rectum; itching after dinner. Worse
at night and in the open air. Better from heat.
Ignatia.-Itching and creeping in the anus, with stitches running up the rectum.
Constriction of the auus after stool. Worse when heated, in the open air, after dinner,
and in the morning as soon as waking. Better from scratching, if the skin is not
broken.
Lycopodium.-Itching and tension of anus, which is painful to the touch.
Painful spasmodic stricture of the anus; bruised feeling in the perinæum. Itching re-
turns in daytime when becoming warm; humid herpetic eruptions, with rhagades and
Worse from 4 to 8 P.M.
crusts.
Nitric acid.-Itching, burning, and stinging, with humid moisture; feeling of
sharp foreign particles in the anus; itching felt during sleep. Worse on awaking or
touching the parts.
Petroleum.-Herpetic eruption on perinæum and near parts; intense biting
itching, inducing scratching until the parts become raw.
Sepia.—Pain in the rectum as if from contraction, with itching, burning, and
stinging, and discharge of mucus. Worse from mental exertion, washing, or after
eating.
Sulphur.—Itching and formication of the parts, with moist herpetic eruptions,
very greatly aggravated from cold water, or from water of any temperature.
Other remedies may be needed, as Conium, Graphites, Pulsatilla, Rhus,
or remedies mentioned under Prurigo in general.
PROCTITIS-PERIPROCTITIS.
BY A. C. COWPERTHWAITE, M.D., PH.D.
Definition.—Inflammation of the mucous lining of the rectum.
Catarrh of the rectum. In its mild form proctitis constitutes simply
dysentery. Periproctitis signifies an inflammation of the connective.
tissues about the rectum.
Etiology. Proctitis may be caused by taking cold, especially from
sitting on the ground, or on some cold damp object while perspiring.
It frequently arises from the habitual use of medicated injections
which cause excessive local irritation, and from purgative medicines,
especially such as contain aloes. It often results from the accumula-
tion of masses of hardened fæces in the rectum, and thus it may be
said that constipation is the chief cause of proctitis. It may occur
secondarily from inflammation in neighboring organs, or from dis-
eases of the liver, vena porta, heart, or lungs which are caused by an
obstruction of the abdominal veins.
Periproctitis usually follows an extension of inflammation in the
rectum, and corresponding affections of the prostate gland, bladder, or
804
A SYSTEM OF MEDICINE.
uterus, or it may arise from caries of the vertebræ and pelvic bones.
Primarily it is occasionally caused by external violence.
Pathology. The pathological changes correspond in a marked
degree to those of other catarrhal inflammations. Leube* briefly
enumerates the pathology of proctitis as follows: marked swelling of
the mucous membrane, blenorrhoea, branny diphtheritic deposits,
ulceration, polypoid proliferations, and finally hypertrophy of the
submucosa and musculosa. This hypertrophy is at times so consid-
erable as to convert the rectum into a "thick indurated tube," and is
firmly bound by the proliferated tissue in its vicinity. At the same
time the intestine above the inflamed part is dilated and impacted
with fæces, while the rectal veins, particularly those of the anus, are
engorged (hæmorrhoids). The venous engorgement is due partly to
the incessant irritation of the mucous membranę, and partly to purely
mechanical causes, such as the impediment presented by the condi-
tions above mentioned to the return of blood from the hæmorrhoidal
plexus.
Periproctitis, when dependent upon intestinal inflammation,
may terminate in two ways, either in an absorption of the inflamma-
tory products, followed by induration of the tissue, or the pus formed
may be discharged either externally or into the intestine. In the
latter case, collections of pus, fæces and necrosed shreds of tissue are
formed, which communicate by fistulous openings with the affected
part of the intestine (the so-called internal rectal fistulæ in proctitis).
These secondary collections, in their turn, may rupture in other direc-
tions; the periproctitic abscesses externally in the anal region with
the establishment of a complete rectal fistula, or into neighboring
cavities, such as the bladder. In the external rupture the final event
is generally preceded by a burrowing of the pus along the connective
tissue which surrounds the cæcum, ascending colon, and extends
directly to the rectum, kidneys, and superficial fascia of the upper
part of the thigh.
Symptomatology. In the milder form of proctitis the patient.
experiences dysenteric symptoms, tenesmus being the most prominent,
and the stools consisting of mucus mixed with blood. In severe cases
these symptoms become greatly intensified, the pain being of a burn-
ing character, sometimes tearing and throbbing, often sticking as if
something sharp were irritating the rectum and must be forced out.
The straining is violent, often causing prolapsus ani, the mucous
membrane appearing at its orifice like a dark red cushion, and the
stools contain considerable blood. Neighboring organs become irri-
tated, and, as a consequence, we have strangury, painful urination,
erection of the penis, metrorrhagia, and leucorrhoea. The symptoms
may, after from four to ten days, begin to subside. A free evacuation of
* Ziemssen, vol. vii., page 361.
DISEASES OF THE ORGANS OF DIGESTION.
805
partially normal fæces may occur, and the patient soon recovers without
further trouble. More often, however, either the inflammation extends
to the peritoneum or the adjacent connective tissue (periproctitis), or,
assuming a chronic form, ulceration and sloughing may ensue, render-
ing the stools purulent or muco-purulent, and very offensive. In the
latter case the pains grow less severe and more heavy and dragging
in their character, a continuous discharge of offensive pus takes place
from the anus, the patient slowly becomes weak and emaciated, and
may finally die from extensive ulceration and sloughing, even if per-
foration has not sooner excited a fatal peritonitis. In case the inflam-
mation extends to the connective tissue about the rectum, we obtain
the usual symptoms of an abscess, which may become absorbed, but
more often discharges either externally or internally, or into the rectum,
vagina, or bladder, thus forming different varieties of fistula. Some-
times dangerous complications arise, such as pyæmia, or thrombosis.
of the hæmorrhoidal veins may occur, resulting in the formation of
an hepatic abscess by deposit of emboli.
If peritonitis is established we obtain the usual history of that af-
fection, influenced by the extent and character of the local disease.
Diagnosis. The symptoms of proctitis are so characteristic that
there is little trouble in establishing a diagnosis, though it is some-
times more difficult to ascertain whether the condition is a simple
catarrhal inflammation, or whether it be secondary to some serious
fundamental disease, such as carcinoma, ulcers, or hæmorrhoids. In
such case the use of the speculum will usually determine. In case
there is reason to suspect that the inflammation is due to irritation
from a displaced uterus, a vaginal examination may be required.
From severe dysentery proctitis is usually distinguished by the ab-
sence of the flatulent stools and of the general constitutional disturb-
ance so characteristic of the former.
Prognosis. The prognosis is usually favorable; it is unfavorable
only when the existing cause can not be removed. This is especially
the case when proctitis results from some dyscrasia, as in tuberculous
or cancerous conditions. Also in obstructive disease of the liver, heart,
or lungs, more especially when abscesses of the liver have followed
thrombosis of the hæmorrhoidal veins, as before mentioned.
Sometimes, when the disease is due to the presence of foreign bodies,
fæcal masses, etc., which have been allowed to remain until extensive
and deep ulceration has taken place, or periproctitis has supervened,
the prognosis is not favorable, especially in weak or tuberculous pa-
tients. In cases of perforation resulting in peritonitis the prognosis
is extremely unfavorable, and hardly less so when peritonitis has re-
sulted from an extension of the inflammation by the contiguity of
tissue.
Treatment. When proctitis arises from local irritation, as after
806
A SYSTEM OF MEDICINE.
the use of medicated injections or purgative medicines, it is often
necessary to employ an enema as a soothing and healing applica-
tion. For this purpose a simple injection of warm water is all that
is required, though a flax-seed emulsion is usually most desirable.
Sometimes an injection of equal parts of Glycerine and Calendula
tincture will answer even better. In case the inflammation arises from
an accumulation of fæces it is of the utmost importance that these be
removed at once by a copious enema of hot water, which should be oc-
casionally repeated in order to prevent a recurrence of the accumula-
tion. At the same time the diet should be carefully regulated with
the same object in view, the patient being restricted to the use of milk,
corn starch, mutton broths, and such food as leaves little fæcal resid-
uum. The medicinal treatment is precisely the same as in dysentery,
the chief remedies being Nux vomica, Mercurius corr., Cantharides, Arsen-
icum, Nitric acid, and Rhus tox., for the indications of which the reader
is referred to the article on dysentery.
INTESTINAL WORMS.
BY A. C. COWPERTHWAITE, M.D., PH.D.
Synonyms.-Intestinal parasites, Entozoa, Enthelminthes, Hel-
minthiasis.
History. That some sort of a parasite at times infests the intestinal
canal of man has been known since the earliest times, but almost ab-
solute ignorance prevailed in regard to their respective forms and
characters. The Greeks went so far as to distinguish by their form
three varieties, -the tape-worm, the round worm, and the thread-worm,
which are described by both Hippocrates and Aristotle. Amongst the
Romans, Galen also distinguished these three forms, but Celsus and
Pliny only described two species, the broad and the round worm, em-
bracing the thread-worm in the latter variety; at a still later day, the
Arabians held that aside from the round worm the tape-worm is the
only distinct species. This view was generally entertained until the
seventeenth century. In 1691, the independent nature of the "hydatid
Cyst" was established by Tyson.* As late as 1766, it was stated by
Pallas that all the cystic worms were forms of tape-worms belonging
to one species-namely, the cystic or hydatid tape-worm, and he first
taught that entozoa, like other animals, spring from similar parents,
and are propagated by means of eggs which are transmitted from one
host to another, though he was not able to demonstrate how this is
accomplished; at that time the doctrine of spontaneous generation was
generally accepted.
In 1808, Rudolphi published his systematic treatise on Entozoa,†
* Phil. Trans., cxiii., page 506.
† Entozoor. Hist. Natur.
DISEASES OF THE ORGANS OF DIGESTION.
807
and in 1819 Bremser's work was issued. Both these authors as-
sumed the theory of spontaneous generation, the correctness of which
was soon destined to be overthrown by the investigations of von
Siebold (1835) and Eschricht (1837), who held that the entozoa
during the reproduction generally undergo a metamorphosis and a
migration. These views were subsequently confirmed by Steenstrup,†
in 1842, who discovered that amongst a certain class of minute Cercaria
(worms of a microscopic size found in stagnant water), their generation
was carried on through a series of broods produced from one parent,
each brood differing from the parent and from each other. This dis-
covery he described under the "alternation of generation," and from
it deduced the conclusion, afterward verified by von Siebold (1848)
and Van Beneden (1850), that the hydatid cysts would be proved to
be undeveloped tape-worms, each cyst capable of producing a tape-
worm after its kind. It now only remained for Kückenmeister, in
1852, to establish a series of experiments to conclusively prove the
correctness of Steenstrup's views. This he accomplished by feeding
carnivora on flesh containing cysticerci and producing tape-worms, and,
on the other hand, by feeding herbivora with the ova of tæniæ and
producing cysticerci. These results have subsequently been confirmed
by several distinguished investigators, so that it is now generally held
that the ova or embryos are admitted from without, and conveyed into.
the intestinal canal by articles of food and drink.
Varieties. It has only been a few years since accurate informa-
tion has been had as to the great number of species of entozoa which
exist, and even now new observations constantly increase their list.
At present it is supposed that there are about fifty animal parasites
which infest the human body; of these, twenty-one inhabit the intes-
tinal canal, though of this number only eight are peculiar to man, and
to them our remarks will be limited. Of these latter, three belong to
the order of Cestoda, or tape-worms, and five to the order of Nema-
toda, or round worms.
Tænia solium.
Cestoda
Nematoda
Tænia saginata.
Bothriocephalus latus.
Ascaris lumbricoidis.
Oxyuris vermicularis.
Trichocephalus dispar.
Trichina spiralis.
Anchylostomum duodenale.
Ordinarily, but one of these varieties infests the human intestine at
the same time, though many cases are reported where two have been
* Ueber lebende Würmer in lebenden Menschen.
† Ueber den Generationswechsel.
Prager Vierteljahrschrift.
808
*
A SYSTEM OF MEDICINE.
found, and Rosen reports the case of a child, four years of age, in
whose intestines were found ten lumbricoid worms, an innumerable
quantity of oxyures, and four tæniæ. Heller† holds that different
species are frequently found in the same intestines. He says this is
especially true of the three common round worms, the Ascaris, Oxyuris
and Trichocephalus, which are very often found in company. In like
manner we may meet with these in company with tape-worms, and
even the different varieties of tape-worms may take up their abode,
side by side, in the same intestine. Heller also holds that the Ascaris
and Oxyuris, or, as the vernacular has it, the round worm and the
thread-worm, are, like tape-worms, found oftener in adults than in
children, which is quite contrary to the views usually held by authors.
Natural order Cestoda.-Ransom ‡ describes the varieties of ces-
toda as parenchymatous worms, "without mouth or alimentary canal,
with a so-called water-vascular system. They develop by budding from
a pear-shaped larval form to a long, jointed, tape-shaped colony of in-
dividuals. In their reproduction they suffer an alternation of genera-
tions. The individual members of the colony (proglottides), or sexu-
ally ripe animals, increase in size and complexity of structure, although
otherwise resembling each other, the further they are removed from
the head, near to which a continuous formation of new joints takes
place by budding. The head, which is the same in the adult as in
the larval form, is furnished with two or four suckers, and commonly
also with a coronet of hooklets, which serves for attachment. They
infest, in their adult state, the alimentary canal of vertebrate animals
only," their habitat being the small intestines, though, when very long,
the worm may reach into the large intestine.
Etiology. The origin of entozoa has already been briefly inti-
mated, and in considering the general causes which operate for their
production it is best to more fully explain the manner of their de-
velopment. In the first place, in considering the etiology of intestinal
worms, it must be remembered that the theory of spontaneous genera-
tion from deranged intestinal conditions is now a thing of the past.
The eggs or embryos must be introduced into the system from with-
out, nor will an intestinal worm develop in the bowel directly from an
ovum deposited there by a previous tenant, but it must first be dis-
charged and undergo metamorphosis, being afterwards conveyed by
some means through the mouth into the alimentary canal in a certain
stage of development; when the parasite thus reaches its peculiar
habitat, it grows into the adult animal.
Accurate observation and experiments have established the fact that
the Cestodæ are cystic entozoa, known as cysticerci, in a state of ma-
* "Traité des Entozoaires et des mal. Verm.," par C. Davaine, Paris, 1879.
† Ziemssen's Cyclopædia, vol. vii., p. 675.
Reynolds's System of Medicine, vol. iii., p. 277.
DISEASES OF THE ORGANS OF DIGESTION.
809
turity. Different varieties of cysticerci are found in the solid parts of
different animals, and each variety, received into the alimentary canal
of another animal and there finding favorable conditions, becomes a
perfect tænia, each kind of cysticercus becoming a particular kind of
tænia. A cysticercus, on the other hand, is the product of the ovum
of a tænia. The last links of the tænia, known as proglottides, which
contain the ripe eggs, occasionally drop off and are evacuated.
In order to develop further, the embryos from the eggs must enter some
other animal. If they are swallowed by some animal, they pass from
the intestines into the tissues of the body, till they find a suitable place;
then they throw off the little hooks, and a neck and head (scolex), re-
sembling those of the tape-worm, grow from their wall. At first the
scolex is inclosed within the embryo; it subsequently becomes free,
and the swollen body of the embryo hangs to it like a bladder. This
constitutes, at this stage, the cysticercus, or bladder-worm, such as is
seen in the muscles, liver, brain, and other organs and tissues of dif
ferent animals, and sometimes in human beings. The most common
variety of cysticercus is that found in the swine, called the cysticercus
cellulosus, which constitutes the scolex of the tænia solium. The sco-
lex of the tænia saginata is found in beef, and is usually termed the
cysticercus medio-canellata. The scolex of the bothriocephalus latus,
or tænia lata, has more effectually eluded investigation, but is sup-
posed to exist in fish or mollusks. If one of these scolices enters the
intestines of a human being it becomes attached by the head to the
wall, drops the bladder-like tail, and then a succession of segments
form, constituting the tape-worm. They are generally introduced by
eating the raw or imperfectly cooked flesh of the animals which they
infest. Thus the taenia solium results from eating pork, while the
taenia saginata is acquired by eating beef, and it is supposed the tænia
lata from eating fish or from drinking water into which the larvæ
have been deposited. Occasionally, the cysticerci may be introduced
with other articles of food which have been in contact with the in-
fected meat, and to which the embryos have adhered, or which have
been cut with a knife that has been previously used for cutting in-
fected meat. Tape-worm is far more frequent in those countries where
much pork is eaten, and persons who do not eat pork, as the Jews, are
particularly exempt from the disease. Tænia saginata is the variety
mostly found in England and America, as might be expected from
the large amount of beef consumed, though the taenia solium is of not
unfrequent occurrence. The taenia saginata is most prevalent in Africa
and Asia. It is said that the Abyssinians, almost without exception, are
infested with this variety, and it is well known that the use of the raw,
still quivering cow's flesh is looked upon by them as the greatest deli-
cacy. The bothriocephalus is prevalent in Eastern Europe as far as the
Vistula, especially along seacoasts and rivers, and in Switzerland. The
810
A SYSTEM OF MEDICINF.
habit of feeding children and invalids with raw beef has been known
to produce tape-worm. Cysticerci cannot withstand boiling, roasting,
and smoking, and infested meat thus treated in a thorough manner
never produces tape-worms.
Pathology. The disorders generally caused by tæniæ are simply
functional, and such as result from the irritation to the mucous sur-
face by the movement of the tape-worm. Leuckart has shown by
observations on the dog that local congestions of the mucous mem-
brane, separation of the epithelium, and even minute superficial sores.
may occur, and we have reason to infer that similar changes take
place in man, though as yet they have not been demonstrated.
Symptomatology.-The symptomatology of tape-worm is quite
indefinite, and often exceedingly obscure. Probably, in a majority of
cases, there occur no symptoms whatever until fragments of the worm
are passed at stool. There are, however, functional disturbances,
already mentioned. Frequently, patients will complain of a severe
twisting pain in the abdomen, like colic, and will bend double, or press
the abdomen against some hard substance, suffering from nausea and,
sometimes, vomiting. They may also have more or less itching about
the nose and anus, disturbed sleep, anorexia, or a voracious appetite,
frequently followed by fainting if not satisfied, and diarrhoea alternat-
ing with constipation, headache, ringing in the ears; the disposition.
is fretful, and the mind greatly depressed. As a rule, all these symp-
toms are worse when fasting, and are at once mitigated by eating.
In addition, there exist sympathetic disturbances which sometimes
assume a grave character, hæmorrhages, menstrual irregularities, hys-
terical fits, chorea, convulsions, and even epileptic and maniacal
attacks.
These, however, are so liable to occur from other causes coincident
with the tape-worm that they should be received with much caution,
and frequently they do not disappear long after a tænia has been
discovered and dislodged.
Diagnosis.—It is not only quite important to recognize the actual
presence of a tape-worm, but it is also important to distinguish the
variety, in order to anticipate the amount of resistance to measures of
relief, a fact often overlooked by the average physician. From a di-
agnostic point of view, the symptoms already described are of but
little importance, as they are by no means characteristic of worms, so
that we are unable to positively predict their existence until it is
known that the proglottidis has been expelled. Segments of the tænia
saginata are usually expelled spontaneously, but this is seldom, or
never, the case with the tænia solium, it often being necessary and jus-
tifiable, in strongly suspected cases, to administer a purgative in order
* Die Menschlichen Parasiten, etc., 1862-1868.
DISEASES OF THE ORGANS OF DIGESTION.
811
to secure the segments for examination and diagnosis. The segments
of the tænia solium are much thinner, softer and more transparent,
and the lateral branches going off from the uterus are only from nine
to twelve in number, while the tænia saginata has from fifteen to
twenty. The segments of the bothriocephalus are seldom expelled
singly, but usually several joined together, and in each may be seen a
brown spot formed by the uterus, which is not shown in the other
varieties.
Prognosis. The prognosis is always favorable, there being no rea-
son why the worms should not be dislodged if properly treated. It is
necessary to insure the discharge of the head, else a further growth
will probably take place. Tape-worms may infest the bowels for many
years, yet no serious consequences ensue, as a parasite seldom destroys
the life of the animal from which it derives its own subsistence.
Sometimes, by their migrations, or by causing obstruction of the bowels,
worms may become dangerous, and death may occur in children from
reflex convulsions excited by their agency.
Description.-The tænia solium, or solitary tænia, was so called
because it was supposed to always exist singly, but it is now known
that two, or more, occasionally exist in the same intestine. The worm
varies in length from seven to thirty feet, and in exceptional cases is
very much longer. The head is very small, somewhat globular or
bulbous, with a slightly prominent conical snout in front, surrounded
by a double row of hooks, about twelve in each row, and four project-
ing suckers. The neck is extremely slender, like a thread, about an
inch long, and transversely marked. The segments in their earliest
form are very small, much broader than long, gradually becoming
more flattened and altered in the relation of their diameters, so as to
be first square, and afterwards oblong, being much longer than broad,
with the ends narrowed, especially the anterior extremity. Mature
links are about one-half of an inch long and one-fourth of an inch
broad. The male and female sexual organs open by a common aper-
ture, which is situated near the centre in a little projection, now on one
side and then on the other, but not regularly alternating.
The taenia saginata has been confounded with the tænia solium.
Its links are very similar, but are somewhat broader and thinner and
are more numerous, the entire tænia commonly attaining a greater
length. The unripe segments are broader than long, and those ripe
are longer than broad. The head is larger, and has neither snout nor
hooks, being flattened in front, but is furnished with four very power-
ful and prominent suckers, and, according to Leuckart, a fifth smaller
one between them. The common sexual orifice is situated alternately
near either posterior border, and the organs are more fully developed
and divided. This is the largest tape-worm known to infest man. The
bothriocephalus latus resembles the tænia, but may be readily distin-
812
A SYSTEM OF MEDICINE.
guished from it. The head is obtuse or club-shaped, and, instead of
the snout, hooks and suckers, we find only two longitudinal slits or
grooved suckers on each side. The neck is so short, it can hardly be
seen. The segments are very numerous, their breadth being much
greater than their length, and they have a slightly brownish color.
The sexual orifices are not at the side, but in the middle of the links,
and are distinct, that of the male apparatus being anterior.
A tænia, called the bothriocephalus cordatus, distinguished by the
form of the head, is common in dogs and has been found in man, but
its importance is not such as to merit consideration here.
Treatment. From our present knowledge of the causes which
give rise to tape-worm, it is quite evident that the only preventive
measures consist in an abstinence from the use of raw or imperfectly
cooked meat. As has been stated, the cysticerci cannot withstand
boiling, roasting, or smoking, and meat so treated cannot produce
tape-worm. In countries where the bothriocephalus latus is found, it
is necessary to avoid the use of impure drinking water, especially that
coming from sources where fish abound. The first step in treatment
is to rid the system of the invader, after which the symptoms which
have resulted from its presence, or which may have been produced in
the efforts made to dislodge it, are to be removed by the use of the in-
dicated homœopathic remedy, together with such a diet as the indi-
vidual case seems to demand.
Before administering the tænicide, the patient should be placed on
a low diet for a few days, avoiding such articles of food as are digested.
in the small intestines, and only eating beef-tea, chicken-soup, milk,
toast, or some light food which leaves little residuum. German phy-
sicians put their patients on a diet of onions, garlic, and salt-herring,
for the reason that these articles are known to be obnoxious to the
The medicine may then be administered, and after a few
hours an active purgative given to expel the dead parasite. In case
the head is not discharged there is no certainty of the success of the
treatment, but further means for its removal should not be employed
until fragments of the worm are again discharged.
worm.
Male fern or filix mas is the oldest and probably most popular tæni-
cide. It is best administered in capsules containing one half to one
drachm of the ethereal extract. The oil may also be given in drachm
doses, in mucilage with milk.
The bark of the pomegranate root (Punica granatum) is an excellent
tænicide. The fresh bark only should be used. About two and one-
half ounces should be boiled in a pint and a half of water until the
quantity is reduced one-half, this amount being taken in three doses
within an hour.
Kückenmeister strongly advises the addition of twenty or thirty
grains of the ethereal extract of male fern. The tannate and sulphate
DISEASES OF THE ORGANS OF DIGESTION.
813
of pelleterine, the active principle of the pomegranate, have both been
successfully used to remove the tape-worm.
Kousso, the flowers and tops of the Brayera anthelmintica, a tree of
Abyssinia, a country where the tape-worm abounds, is considered an
effective tænicide and is much used for the species there prevalent.
It may
It has also been used with success in Europe and America.
be given in doses of one-half ounce of the powder. Heller prefers to
give it in compressed balls or disks coated with gelatine. He considers
five drachms necessary for the tænia solium, and seven and a half
drachms for the tænia saginata. The balls or disks should be placed
on the back part of the tongue and swallowed alone, or by the aid of
some coffee. After this, the tendency to vomiting should be resisted,
with the assistance of lemon-juice, mustard applied to the epigastrium,
bits of ice swallowed, and by maintaining the recumbent position.
He advises an ounce, or two, of castor-oil two hours later, to expel the
worm speedily and entire. Koussin, an alcoholic extract, is now used
by some in thirty-grain doses instead of the crude drug.
Kameela, the glandular powder and hairs from the capsules of the
Rottlera tinctoria, is an efficient and not unpleasant tænicide. It may
be given in doses of from one to three drachms, prepared in a gum-
arabic emulsion, and repeated every three hours if necessary. No
purgative is required to follow. If two or three doses do not prove
effectual add about one drachm of the oil of male fern, and repeat.
Pepo semen, an emulsion of pumpkin-seeds, is ranked in this country
as one of the best tænifuges. It possesses the advantage of producing
no unpleasant, injurious effects. The emulsion is prepared by rubbing
up about two ounces of the fresh seeds in a mortar with a pint of
water, and straining through a cloth. To this a drachm of sulphuric
ether should be added, and the whole quantity taken at one dose in
the morning on an empty stomach. If the first dose is not effectual,
it may be repeated each morning for several days.
Turpentine is an efficient tænicide, but its unpleasant taste and the
ill effects following its use have prevented its general employment,
save in cases which have resisted other methods of treatment. It may
be given in half-ounce doses every half hour until two ounces are
taken. Bartholow advises uniting with it an equal amount of castor-
oil. It is probable that any of the medicines before mentioned are
equally effectual and less injurious to the system.
Order Nematoda.-Ransom * describes this order as "elongated,
slender, often thread-like worms, not distinctly jointed, or provided
with appendages; with a separate alimentary canal, a terminal mouth,
an anus near the caudal extremity, opening on the ventral aspect.
The integument is marked by two longitudinal bands, and often by a
* Reynolds's System of Medicine, vol. iii., p. 284.
814
A SYSTEM OF MEDICINE.
dorsal and ventral one; in the former are imbedded the nerves with
their ganglia and the excretory tubes, which open in the surface about
the level of the pharynx."
"The female aperture is placed about the central region of the body,
that of the male near the anus, and conjoined with it; it is furnished
with retractile spiculæ, usually two or more. The male is smaller than
the female. The development is direct, and the metamorphosis incon-
spicuous, so that the embryo has the general aspect of the nematode
worm. The order is rich in species, and furnishes as many parasites
as all the other Helminthoids put together. They infest invertebrata
as well as vertebrata, and no organs escape their invasion."
The ascaris lumbricoidis, or round worm, is the most common of all
intestinal worms, and exists most often in children between three and
ten years of age. It is elongated, cylindrical, and tapering at both
ends, from six to twelve inches long, and from two to three lines thick.
The body is of a whitish or yellowish color, and almost transparent,
firm, and elastic. The head is separated from the body by a circular
depression, and has three small elevations, between which lie the
teeth. The male is smaller than the female, and curved at the tail-
end, where the sexual organs are placed. The female is about one
third larger and is straighter and thicker at the tail-end, and has the
sexual opening near the end of the upper third. It has been esti-
mated that a female ascaris lumbricoides contains sixty-four million
eggs.
The round worm inhabits the small intestine, but frequently passes
into the large intestine, and out through the anus. It not unfrequently
migrates into the stomach, œsophagus, and has also been known to
find its way into the nares, Eustachian tube, frontal sinus, larynx, pan-
creatic and biliary ducts, and gall-bladder. Flint* cites a case in a
subject dead with lumbar abscess, connected with caries of the verte-
bræ, in which a great number of these worms were found within the
hepatic ducts, some extending along the ducts and others coiled up.
It is not probable that they can perforate the intestine, but if the intes-
tine be perforated by any disease, we not unfrequently find round
worms in the cavity of the abdomen. They often occur in great num-
bers. Cruveilhier cites a case in which over a thousand were found
after death.
The oxyuris vermicularis, or common seat-worm, also known as the
thread, pin, or maw worm. This worm varies in length from one to
five lines, resembles in appearance and size a piece of fine sewing-
cotton, the female being about twice as large as the male. They are
whitish, semi-transparent, their surface presenting fine transverse striæ.
The head is furnished with three inconspicuous lips around a terminal
mouth, and an elongated vesicular expansion on the dorsal and ven-
(6
* Clinical Medicine, p. 512.
DISEASES OF THE ORGANS OF DIGESTION.
815
tral aspects." The male is rolled up posteriorly, where the sexual
organs are placed. The female is but slightly bent, and its vulva is
situated at about the junction of the anterior and middle thirds. This
worm inhabits the large intestine, chiefly the rectum, rarely passing
into the small intestine. They often crawl out of the anus and enter
the vagina or urethra, or get under the prepuce. They occur chiefly
in young children, but no age is exempt from their presence. They
frequently exist in great numbers, hundreds and thousands lining the
intestines, and sometimes passing off during stool in large masses or
balls, agglomerated by mucus.
-
The trichocephalus dispar, the hair-headed or whip worm, is about
an inch and a half or two inches long; the posterior part is quite
thick, the anterior hair-like, ending in a simple terminal mouth. In
the male, which is the smaller, the posterior part is wound into a
spiral, and has at its end the hook-shaped penis, surrounded by a bell.
The female is larger and thicker, and only slightly curved, and its
posterior end contains an immense number of eggs. They inhabit the
cæcum especially, but are sometimes found in the colon, and, very
rarely, in the small intestines. They do not occur in as great numbers
as do the other varieties of nematodes already mentioned.
The anchylostomum duodenale is a small cylindrical worm, five to
eight lines in length, the female being twice as long as the male. The
terminal mouth is surrounded by a thin capsular expansion, which is
directed obliquely backwards. The upper side is furnished with four
small teeth, and the opposite side with four larger teeth. The vulva
of the female is placed a little back of the centre. This parasite in-
habits the duodenum or jejunum, where it is present in very large
numbers.
The nematodæ vary so in their individual characteristics and in the
morbid phenomena which they produce that they will require separate
consideration.
ASCARIS LUMBRICOIDIS.
Etiology. The ascaris lumbricoidis is propagated by ova, and
probably without the aid of an intermediate bearer, though this point
is not yet established. The eggs being expelled with the fæces, and
often in countless numbers, gradually develop an embryo in damp
earth or water. Both the eggs and the embryo seem indestructible,
either by freezing or desiccation, and retain their propagating power
for years. Davaine maintains that the ova, with their contained em-
bryos, are swallowed with impure water, and develop directly into the
adult form if received into the intestine of a suitable bearer. Others
hold that this is not the case, but that it is far more probable that the
ova are not transferred directly into the intestine of the ultimate
bearer, but are taken up in some manner by an invertebrate interme-
diate bearer, possibly a worm, or the larva of an insect, thus passing
816
A SYSTEM OF MEDICINE.
through the necessary stages of metamorphosis, and then being dis-
charged are received into the stomach of the future host through the
medium of food or drink. It is especially conceded that they are first.
introduced into the system through drinking water; thus it follows.
that in the country, and in other places where excreta easily gain
access to water, and people are careless in their habits, the ova are
rapidly disseminated through the water drank. They may be propa-
gated also in the same manner through certain foods, such as fruit,
vegetables, salad, and other articles which are eaten in the raw state.
It is necessary, however, that the ova or embryos find a congenial soil
for their development. This condition results chiefly from uncleanli-
ness, and thus the ascaris thrives among the least cultivated nations,
and, as a rule, among the lower class of people. Those who live in
almost total disregard of sanitary requirements are especially liable to
worms, their food being inferior in quality and poorly prepared, and
their streets and surroundings being filthy and insalubrious. Con-
tinued indigestion, accompanied by irritation or inflammation of the
mucous coat of the intestines, with excessive mucous secretion, espe-
cially in children, seems to predispose to the generation or develop-
ment of worms. It has been frequently noted that children in the
last stages of typhoid fever often pass lumbrici in the evacuations, but
this may only be a coincidence.
Symptomatolgy.-Probably in a majority of instances there are
no symptoms of any kind present, it being nothing unusual to have
lumbrici pass from the stomach or bowels of persons who had expe-
rienced no inconvenience or disorder of system whatever. Occurring
in large numbers, and especially so in delicate persons, they may pro-
duce a variety of phenomena, mostly indicating disorder of digestion,
nutrition, or of the nervous system, with constant reflex manifesta-
tions. The most common symptoms are: itching of the nose, colic-
like pains around the navel, boring and tearing pains in the abdomen,
inflation of the region of the stomach, changeable appetite, and diar-
rhoea, with the expulsion of masses of mucus, occasionally tinged
with blood. There is often also some swelling of the face, darkening
of the eyelids, unequal dilatation of the pupils, foul breath and gen-
eral emaciation. Nervous symptoms, such as irregular pulse, un-
pleasant dreams, grinding the teeth during sleep, and starting out of
it in a fright, are symptoms which, in children especially, are usually
attributed to worms. These symptoms, however, have no diagnostic
value, as they may be present with other varieties of worms, and even
when no worms are present. Choreic conditions and epileptiform con-
vulsions may result from worms and cease on their removal, and
death has been known to result from convulsions so caused. Obstruc-
tion of the bowels, with its consequent phenomena, may result from
a bundle of worms, either in the bowel or in a hernial protrusion, and
DISEASES OF THE ORGANS OF DIGESTION.
817
when these worms migrate into other organs and passages, as they
sometimes do, serious consequences may arise, the symptoms varying
with the part visited. Especially do we find lumbrici in the larynx,
producing symptoms of suffocation, and in the common duct, which
they obstruct, causing jaundice, and ultimately serious derangements
of the liver. Abscesses may also result from the local irritation.
Diagnosis. All the ordinary symptoms of worms are quite insuffi-
cient for diagnostic purposes. Only when worms pass from time to
time, or when a microscopical examination of the fæces has revealed
the presence of ova, can we determine positively that the symptoms
result from their presence in the system.
Treatment. At the present day, since the theory of the sponta-
neous generation of intestinal parasites has been exploded, and it has
been demonstrated beyond question that they are propagated by means
of ova being received into the system through the channels of food
and drink, it is unwise to longer advocate the principles of treatment
as set forth by Hahnemann and his immediate followers. These were
established upon the then prevalent theory that the worms were gen-
erated by morbid conditions of the intestine, resulting from a depraved
systemic state, and were entirely in accordance with that doctrine.
Hahnemann held that intestinal worms could only be successfully
treated by removing by the indicated homœopathic remedy that morbid
condition of the system which caused their generation, and that worms.
could not exist in a previously healthy intestine. It now appears that
these morbid conditions of system are the result rather than the cause,
and while many of the symptoms so arising may be mitigated or,
perhaps, entirely removed by the aid of the indicated remedy, which
may not be a vermicide, it also follows that to render a cure complete
it is necessary first to administer an agent which will destroy the
worm, and afterwards to treat the remaining morbid conditions by
the use of the indicated remedy. It must be admitted that intestinal
worms thrive best in persons of unclean habits, and in those who are
troubled with indigestion and intestinal derangements. It therefore
follows that the preventive measures to be adopted are cleanliness,
regularity in habits, the use of properly prepared food, and, more
especially, the use of pure drinking water, carefully avoiding water
from shallow wells, near residences, barns, or privies, or water obtained
from small streams. It is most desirable to use only well-filtered
water. The diet should be plain, easily digested, and regular, no food
being taken between the usual meals. Cakes, pastry, and sweetmeats
must be forbidden. Salt as a condiment should be freely used.
Santonine, the active principle of Cina, or Artemisia contra, is our
most efficient vermicide. It is usually given in the evening, and in
doses of from two to four grains in powder in the form of troches,
followed in the morning by castor-oil or some other laxative. I have
VOL. I.-52
818
A SYSTEM OF MEDICINE.
found this plan unnecessary, only giving the first or second decimal
trituration four times a day for three or four days. In this manner,
while usually destroying the worms, we fail to obtain the objectionable
symptoms of disturbed vision, red urine, etc., which so frequently
follow the administration of large doses of Santonine. If the worms
are numerous, it is often necessary to persist in the treatment for some
length of time.
Spigelia is also an excellent vermicide, and may be given in doses
of one or two drachms of the fluid extract. It is mostly used in an
officinal preparation, combined with senna.
Cina is more often indicated in the treatment of vermicular affec-
tions than any other remedy; it is often homoeopathic to the existing
morbid condition, and at the same time acts as a vermicide. The special
indications for its use, and for the use of other remedies which con-
trol the conditions arising from the presence of worms, will be given
at the close of this chapter.
OXYURIS VERMICULARIS.
It is generally considered that the oxyuris vermicularis spends its
whole existence, from the egg to maturity, in the intestinal tract of the
same individual, which theory receives the support of Kückenmeister,
Vix, Zenker, Heller,* and many others. Ransom,† however, considers.
that this view is out of accord with the general law of development in
parasitic animals, and does not suffice to explain the known facts.
Leuckart “insists that the emigration of the embryo is a necessary
condition of its future development, and has indeed almost proved the
correctness of this view." He claims "that the ova deposited with the
fæces are abundantly and widely scattered in the dry state by winds
and other agencies, and then are taken into our stomachs upon un-
cooked fruits and vegetables, and in various other conceivable modes;
there, exposed to the digestive fluids, the embryo escapes, is carried
down into the colon, and attains the adult form probably in about two
weeks. A sort of self-infection may take place also; in persons al-
ready infested, it is easy to see how the ova upon the skin and hairs
near the anus may be conveyed to the mouth by the fingers, after
scratching to allay the violent irritation which these small pests pro-
duce; there are various modes in which the eggs may find their way
into the stomach from the soiled bed-clothes or personal linen. These
views explain some long-known facts which are not otherwise easily
understood, for instance, the great length of time for which some
persons suffer from seat-worms, and the liability to relapse in spite of
repeated treatment, the frequency with which these worms are found
inhabiting many members of one family or household, the greater
* Vide Ziemssen, vol. viii., page 754.
† Reynolds's System of Med., vol. iii., page 284.
DISEASES OF THE ORGANS OF DIGESTION.
819
liability of children, of dirty or insane people, and of persons who
often eat uncooked fruits and vegetables, as well as the immunity of
infants at the breast."
Symptomatology.-Only when the worms are located in the
rectum do they give rise to inconvenience. Here they cause pain,
tenesmus, and especially a violent itching and tickling in the anus and
its neighborhood, which is intolerable, and occurs in paroxysms, mostly
at night. Excitation of the sexual organs is apt to occur with seminal
emissions, and it is stated that the habit of masturbation in either sex
may originate from this source. In females, the worms frequently
wander into the vagina, and by their excessive irritation cause pruritus
and leucorrhoea.
Diagnosis. The diagnosis is easily made. Inspection of the fresh
stools will usually reveal worms in active motion, and they may fre-
quently be seen about the anus. If this is not the case, a small in-
jection of cold water will cause those in the rectum to be expelled. A
microscopic examination will reveal the ova-a certain diagnostic
mark.
Treatment. From what has already been said concerning the de-
velopment and habits of this parasite, it is evident that scrupulous
cleanliness is one of the most important prophylactic measures. Close
personal contact, especially occupying the same bed, with infested
persons should be avoided. Only pure water should be drunk, and
the food should be well cooked.
In addition to the indicated remedy required for the correction of
the general health, and the mitigation of the annoying symptoms.
usually associated with the presence of thread-worms, it is quite essen-
tial to destroy and remove the parasites. This is usually accomplished
by the use of injections. Sometimes only cold water is required, though
salt and water is more efficient. Sweet oil, lime-water, quassia, or
turpentine and castor-oil, decoctions of onions or garlic, are sometimes.
employed in the enema. The folds and crevices about the anus and
perinæum and external genitals should be thoroughly sponged out
with a one per cent. solution of carbolic acid, and afterwards anointed
with lard or carbolated oil or vaseline.
TRICHOCEPHALUS DISPAR,
Etiology. This worm is propagated by ova, without the inter-
vention of any intermediate host. The eggs, being expelled with the
fæces, are after a time developed into an embryo. In damp earth or
water, and in warm weather, this development takes place much more
rapidly than in cold or dry weather. The ova or embryos, or both,
find their way into the stomach in some manner, probably upon raw
food, especially fruits and vegetables, and become sexually mature in
from four to five weeks, when they propagate with remarkable rapidity,
820
A SYSTEM OF MEDICINE.
it being estimated that the female uterus contains 58,000 eggs, and that
the annual production is about 400,000. The farther and special æti-
ology of this worm has not been established.
Diagnosis.—The trichocephalus dispar offers no symptoms that are
at all reliable, and a diagnosis is only established by finding the worm
in the fæces, or by examining the fæces microscopically for the char-
acteristic ova.
No treatment has as yet proved available to dislodge them, but it is
a satisfaction to know that they are probably short-lived, and that
their further development may be avoided by proper hygienic meas-
ures, especially by the exclusive use of well-cooked food and pure water.
ANCHYLOSTOMUM DUODENALE.
Nothing is positively known in regard to the manner of propagation
of this parasite; but it is supposed to be swallowed in embryo, with
dirty, slimy water. It occurs only in tropical countries, and as far
north as Italy. It affords no special symptoms, but is supposed, on
account of its blood-sucking qualities, to be the cause of a very fatal
disease known as tropical chlorosis, or Egyptian chlorosis, a peculiar
anæmic condition which is said to follow intestinal hæmorrhage due
to this parasite. Griesinger recommends turpentine as the remedy.
TRICHINA SPIRALIS.
The trichina belongs to the Nematoda, and while, in one sense, it
pertains to a class of general diseases, and is treated of by some authors.
as an infectious disease, it nevertheless attains its state of sexual
maturity in the intestinal tract, where its species is propagated, and
from which locality it migrates to its habitat in the voluntary muscles,
so that it is not inappropriate to consider it in this connection.
History.—The trichina was discovered in 1828 by Peacock. Tied-
mann's claim to having discovered it in 1822 is disputed on very
reasonable grounds. In 1835 Owen described it accurately, classified
it, and gave it the name it has since borne. From that time until
1860 it received the attention of many distinguished pathologists.
whose investigation and experiments were considered of great scien-
tific interest, though it was little thought up to that time that this
seemingly insignificant and harmless intruder was in reality a most
dangerous foe to the health and life of man. In 1860 Prof. Zenker, of
Dresden, aroused the world to the great importance of the subject by
publishing his famous case, which at once revealed the morbid effects
of this parasite, and established a conclusive theory as to its nature
and source. In a young girl who died after an illness of several weeks'
duration, characterized by debility, fever, sleeplessness, abdominal
tenderness, great pain in the muscles, and oedema of the lower extremi-
DISEASES OF THE ORGANS OF DIGESTION.
821
ties, numerous trichina were found in the voluntary muscles and in the
mucus from the small intestines. The origin of the disease was traced
to eating ham and sausages, which, upon microscopic examination,
were found to contain trichinæ in abundance. At the time of this
occurrence Virchow and Leuckart were engaged, independently of
each other, in investigations on trichina. The efforts of these three
observers and, later, of Prof. Dalton, establish the following:
1. Man becomes infected with trichinæ by the use of trichinous pork
(Zenker).
2. The muscle-trichinæ in the stomachs of mice become freed from
the capsules (Leuckart) and develop in the intestines of dogs and cats
(Virchow), as also in that of man (Zenker), to mature sexual worms—
intestinal trichina-which
3. Attain their full growth in about seven days, and give birth to
living young (Leuckart).
4. These young trichinæ migrate directly from the intestine in which
they are situated into the muscles of the same person or animal
(Zenker, Virchow). Since,
5. During their migration, they are found in the mesenteric glands,
abdominal cavities, and pericardium (Virchow).
6. They penetrate into the muscular fibres (Virchow), and cause the
destruction of the contractile substance (Virchow, Zenker).
7. Within the muscles they grow to perfect muscular trichinæ
(Zenker, Virchow, Leuckart).
8. These migratory processes bring about in man a severe febrile dis-
ease, trichinosis (Zenker), which
9. May result in death, both in man (Zenker) and in animals (Vir-
chow).
10. Cases of capsulated trichinæ are to be considered as healed cases
of trichinosis (Zenker).
Description. When expelled from the cyst in its mature state the
male is about one-eighteenth of an inch long, and the female twice
this length. They have the appearance of an extremely fine, round,
thread-like, slightly coiled worm. So long as they remain in the
muscular tissue they are sexually immature and are in a quiescent
state. The sexual system is fully developed in the intestinal canal
of its host, and in the female consists of an ovary, a uterus, and a
vagina. It is viviparous and discharges from the vaginal outlet
about one hundred embryos a week, and the birth of the embryos
begins in about a week after the female enters the intestine. As more
females than males are borne, and as the successive formation of em-
bryos from the eggs may take place, the number developed becomes
enormous. The viable embryos are in lively motion, and at once.
* Conheim, “Zur pathologischen Anatomie der Trichinenkrankheit," Virchow's
Archiv., Band xxxvi., p. 163.
•
822
A SYSTEM OF MEDICINE.
begin a process of migration, finding their way through the blood
(Heller), or the intestinal walls and connective tissue, which is the
route generally accepted by investigators, until they reach the muscles
where they force themselves into the primitive fasciculi, coil into a
spiral form, and become surrounded by a calcareous cyst, which has
an ovoid shape and is visible to the naked eye as a whitish or gray
speck. As intestinal trichinæ the parasites rarely live longer than from
five to eight weeks, but as muscle trichinæ their vitality is almost un-
limited, and frequently ends only after the death of the person af-
fected. Cases are reported showing conclusively that patients have
been affected many years. It is equally certain that the flesh of ani-
mals which have been infected with the parasite ever afterwards may
contain living trichinæ, and could not be eaten with safety. The flesh of
a single trichinous animal may produce trichinosis in a large number of
persons, and thus the disease resembles an epidemic in its prevalence.
Man, the hog, and the rat seem to be the principal hosts of the trichina,
but it has been found in the cat and other animals, as the rabbit,
guinea pig, and dog, though in the latter never developing farther
than the intestinal form. It is found wherever man and swine exist,
being especially prevalent in those sections where pork is largely used
as an article of diet.
Symptomatology. Some authors attempt to divide the symp-
toms of trichinosis into two or three stages, corresponding to the stage
of intestinal development, migration, and encapsulation of the para-
site. This, however, cannot be done with any degree of certainty, as
the symptoms are not uniform in their appearance and duration.
Symptoms of gastro-enteric irritation first make their appearance.
The patient experiences a general feeling of discomfort and fulness in
the epigastrium, the appetite is impaired, emaciation and nausea ap-
pear, and then vomiting occurs, which may end with the first ejection
of the contents of the stomach, or may last with much retching and
anguish for several days. The mouth feels pasty, and the patient.
complains of a loathsome, putrid odor being continually present.
There is almost always diarrhoea, the passages being at first brownish,
subsequently yellow, thin, and accompanied by more or less severe.
colicky pains. The diarrhoea usually lasts for some time, may indeed
continue for weeks and greatly exhaust the patient, but the other
symptoms generally disappear in about one week, giving place to those
which are dependent upon the condition of the muscles. Occasionally
there is an absence of intestinal symptoms in the first stage, and the
patient only experiences a feeling of lassitude and depression, with
wandering pains and stiffness of the limbs. This stage is supposed
to correspond to the introduction of the trichinæ into the intestinal
canal and the commencement of their migration toward the muscles.
DISEASES OF THE ORGANS OF DIGESTION.
823
Flint remarks* that it is not difficult to understand that the aggregated
puncture of the mucous membrane by these parasites should occasion.
notable disturbance, when it is considered that the trichina which
have been found to be contained in a half pound of meat may be
sufficient to give birth in a few days to a brood numbering thirty
millions.
Before the primary symptoms disappear, fever supervenes, which is
probably coincident with the birth of the embryos and the beginning
of migration. The fever is remittent in its character, with morning re-
missions, and usually is quite similar to that of an ordinary case of
typhoid. The temperature runs from 101° to 106°, and the pulse
from 90 to 140, and is usually small and weak. There is an abundant
clammy perspiration, which is not critical and does not relieve the
fever; intense thirst, dry tongue and lips, red swollen face and occa-
sionally sudamina appear. During the existence of the fever, and
some time before its onset, the muscles of the body appear flabby and
are sore to the touch, but Heller remarks that this state must not be
confounded with that condition of the muscles caused by the entrance
of the parasites into them.
The symptoms of invasion of the muscular system supervene about
the tenth day, and vary in severity with the number of parasites en-
tering the muscles, sometimes only amounting to a soreness, but most
often the muscles are hard, swollen, and very tender. The muscles
of the extremities are most affected; those of the trunk to a less ex-
tent. The pains are of a rheumatic character, and may be very vio-
lent. There is great rigidity of the muscles in the neck, back, arms,
and legs, movement being greatly impaired, and the joints in a fixed
state of more or less flexion, any attempt to extend them causing
great distress. From implication of various muscles there may result
attacks of severe dyspnoea, aphonia, difficult mastication, dysphagia,
partial deafness, impaired movement of the tongue, and double or
distorted vision. Edema soon appears in the eyelids and face, which
subsequently extends to the lower extremities, and sometimes anasarca
occurs. The patients are usually sleepless, though their mind is or-
dinarily in a state of apathy and indifference. In children, however,
sleeplessness is not present, a somnolent condition characterizing the
attack throughout. In cases tending towards a fatal issue, low typhoid
symptoms set in, and frequently, about the end of the fourth week,
bronchitis, pleurisy or pneumonia may arise to complicate the case.
The course of the disease may vary from a few hours to several weeks,
according to the number of parasites introduced. Very light cases re-
cover in about three weeks, often not having been confined to the bed,
but in more severe cases, even though of comparatively mild type,
* Clinical Medicine, p. 524.
† Fieckler, Archiv d. Heilkunde, vi., p. 503. 1865.
824
A SYSTEM OF MEDICINE.
convalescence does not begin until the fifth or sixth week, while in
fatal cases this is the time of the greatest mortality. Should recovery
ensue, as it may even in severe cases, from encapsulation and the
consequent quiescence of the parasites, the muscular symptoms sub-
side, the fever abates, but more or less oedema and anæmia remain,
and the exhausted patients gain strength very slowly, often three or
four months elapsing before entire recovery has taken place. In fatal
cases death may occur from pneumonic complications, from impair-
ment of the respiratory muscles, from the presence of the parasites in
them, or from the prolonged suffering and exhaustion. According to
Heller, cases of death after the seventh week are rare.
Diagnosis. The diagnosis is often difficult in isolated cases, but a
diarrhoea, soon followed by the characteristic muscular pains and
lameness, is sufficient to excite suspicions of trichinosis and lead to
investigation, and, if possible, to microscopic examination of the meat
If there is still doubt, a small piece of affected muscle may be
excised and examined microscopically. Ordinarily, the muscular
symptoms are sufficient to distinguish trichinosis from cholera, ty-
phoid fever, and other affections for which it might be mistaken.
From rheumatism it may be distinguished by the gastro-intestinal
symptoms, and by the profuse perspiration, apathy, and great ex-
haustion. After migration has taken place, the symptoms are so
characteristic that the diagnosis can scarcely remain in doubt.
Prognosis. The prognosis is always a matter of doubt, and can
not be positively made. The issue depends upon many direct circum-
stances, but especially upon the number of trichinæ introduced, which
may be fairly conjectured by the number in the meat used and the
comparative rawness of the flesh when eaten. Those cases commenc-
ing soon after eating, and those ushered in violently, are usually the
most severe. Even the severest cases, however, may recover by en-
capsulation of the parasites. Cases in children seldom prove fatal.
The mortality ranges from twenty to fifty per cent.
Treatment.-The results of treatment thus far have proved quite
unsatisfactory. In fact, it is doubtful if there is any remedy, at least
after the parasite has migrated to the muscles.
For the destruction of the trichinæ in the intestinal canal carbolic
acid has been used with apparent success; so, also, has glycerin, which
seems to cause a shrivelling and death of the parasite. After the para-
site has migrated from the intestine, we can only rely on the indicated
homœopathic remedy to control the symptoms that may arise. Hot
baths, friction, with salt and massage, are said to be important auxil-
iary measures. The patient should be sustained by the use of milk,
beef-tea, eggnog, etc.
The only preventive measure is to abstain from the use of all pork,
ham, or sausage that is not thoroughly cooked.
DISEASES OF THE ORGANS OF DIGESTION.
825
General Therapeutic Indications for Intestinal Worms.
In addition to the methods suggested for the destruction and removal
of intestinal worms, our Materia Medica affords a number of remedies
which have been proved valuable for the relief of symptoms associated
with the presence of these parasites or which remain after their removal.
Cina is our most important remedy. It not only covers the range of symptoms
most often found in connection with the presence of round or thread worms, but con-
taining Santonine as its active principle, it is practically a vermicide, and frequently
the only remedy required for the removal of the parasites and the symptonis they
may have produced. Its chief indications are: child irritable and cross; has dark rings
around the eyes, and a sickly expression; white and bluish around the mouth;
tossing about in sleep, with sudden cries; boring in the nose with the finger; grind-
ing the teeth at night; great hunger, or loathing of food; nausea and vomiting; ab-
domen hard and distended; twisting, colicky pains; itching of the anus; turbid urine;
dry, hacking cough, which causes gagging; twitching of the muscles, and convulsive
motion of the head and limbs; fever, usually intermittent or remittent in its character.
Ignatia.-Especially in mild, nervous children. Itching and crawling at the
anus and in rectum, as from thread-worms; prolapsus ani; epileptiform convulsions.
Mercurius.-Excessive hunger; salivation; fetid odor from the month; abdo-
men hard, distended, and painful; glandular swellings; will sometimes cause discharge
of ascarides or of lumbrici without other aid.
Aconite.-Worm-fever. Excessive restlessness, face red and pale alternately;
loathing of food; intolerable nightly tingling and itching at the anus as from thread-
worms.
Spigelia. Nausea every morning, better after eating; squinting; sensation of a
worm rising in the throat, better after eating; itching and tingling in anus and rectum.
Sulphur.-Especially after other remedies have failed; excessive, ravenous hun-
ger, though the stomach feels full and distended after eating but little; nausea before
meals, and gone, faint feeling about 11 A.M.; abdomen distended; itching and crawl-
ing in rectum and anus; turbid urine; emaciation and debility.
Calcarea ostrearum.-In leuco-phlegmatic children, especially when there
seems to be a hereditary predisposition to worms; abdomen hard and much distended;
children of a scrofulous habit.
Consult also Terebinthina, Stannum, Cinchona, Ferrum, Sabadilla, Ur-
tica urens, Teucrium (thread-worm), Antimonium crud.
E. DISEASES OF THE PERITONEUM.
PERITONITIS.
BY A. C. COWPERTHWAITE, M.D., PH.D.
Definition. An inflammation of the peritoneum. It may be
either acute or chronic, or partial, being limited to only a portion of
the membrane, or general, involving the whole peritoneal sac.
History. Owing to the tendency of the abdominal viscera to par-
take of any disturbance occurring in the peritoneum, and the symp-
toms of the former being so much better understood than those of the
latter, it was generally supposed, until a comparatively recent date,
that the peritoneum was not the subject of primary inflammation, but
826
A SYSTEM OF MEDICINE.
that it was necessarily, from contiguity of tissue, involved secondarily
in the diseased processes occurring in the viscera themselves.
It was only in the latter part of the last century that an effort was
made to establish serous inflammation as an independent disease, ana-
tomically distinct from inflammation of the abdominal viscera. Even
at this day some authors hold that peritonitis cannot occur as an idio-
pathic affection, but modern anatomical and histological researches,
together with the results of careful clinical observations, seem to estab-
lish beyond question the independent character of this affection.
True, in most instances the abdominal viscera become involved in the
inflammatory action, but this may be secondary, due to an extension
of the disease from the peritoneum.
In idiopathic peritonitis resulting from cold or unknown atmos-
pheric influences, the inflammation is considered rheumatic in its
character.
Peritonitis occurs as a secondary affection by the extension of the
morbid process from adjacent organs or tissues, and this is usually evi-
dent by the exciting symptoms of visceral disease obtaining prior to
the appearance of the symptoms indicating peritoneal inflammation.
Peritonitis occurs in all ages and conditions of life, from infancy to
old age, and in the robust and healthy as well as in the feeble and
constitutionally diseased.
It may occur sporadically or prevail as an epidemic, in which latter
class is included that form of peritonitis which is incident to the puer-
peral state. Owing to the intimate anatomical relations of the perito-
neum with the female generative organs, and its sympathy in the dis-
orders peculiar to those organs, peritonitis is of much more frequent.
occurrence in the female than in the male.
Etiology.-Idiopathic peritonitis is of rare occurrence, but may
result from exposure to intense cold or to sudden changes when over-
heated, from unknown atmospheric influences, or from severe and
protracted counter-irritation by blisters; it has also been attributed to
over-eating and over-drinking, blows on the abdomen, and other in-
juries, the etiological relations of which to peritonitis haye probably
been much exaggerated.
Peritonitis most often occurs from an extension of some lesion of
the abdominal viscera, an occurrence likely to take place since the
connective tissue stroma of these organs and the serous membrane
form one continuous whole.* Thus the various pathological processes
set up in these organs may give rise to a local inflammation of the
contiguous peritoneal investment, which may either remain circum-
scribed and constitute what is termed partial peritonitis, or may ex-
tend and become general; of this nature is the peritonitis accompany-
ing gastritis, hepatitis, splenitis, or dysentery, or which results from
* Bauer (Ziemssen), page 224, vol. viii.
DISEASES OF THE ORGANS OF DIGESTION.
827
typhlitis, strangulated hernia, internal strangulations, or intussuscep
tions of the intestines, or pelvic peritonitis, by the extension of local
inflammation in the uterus and its associate organs.
Probably the most frequent cause of peritonitis is perforation of the
stomach or intestines, more often of the latter, the gaseous, and other,
contents of the alimentary canal escaping into the peritoneal cavity
and exciting inflammation. This may occur in connection with gastric
or duodenal ulcer, or result from the intestinal ulceration incident to
typhoid fever or tuberculosis, and not unfrequently from ulceration
of the vermiform process.
Perforation, leading to peritonitis, may also result from mechanical
violence. Foreign bodies, such as intestinal calculi or parasites, finding
their way into the peritoneal sac, either with or without previous ul-
ceration, may excite peritonitis.
Peritonitis may result from menstrual congestion, or the habitual
suppression of the menses, or suppressed lochia, and may follow the
injection of cold water or irritating fluids into the cavity of the uterus.
It may arise from septic influences; this is frequently observed in
Bright's disease and in connection with the puerperal state. The con-
dition known as puerperal fever usually, but not necessarily, involves
an inflammation of the peritoneum. This may be a simple inflam-
mation proceeding from the uterus and its appendages, such as may
take place independent of the puerperal state, or, more often, it may be
the result of pyæmic or septicæmic influences, and thus may be con-
veyed by contagion, becoming epidemic, especially in lying-in hospi-
tals. That this condition is not dependent upon the puerperal state,
per se, but rather upon the blood-poisoning, is evident from the fact
that the same conditions may arise after surgical operations upon the
organs. The prevalence of epidemic erysipelas during an epidemic of
puerperal fever, and the apparent production of the latter by the con-
tagium of the former, would seem to establish an intimate etiological
and pathological relationship between the two.
Peritonitis may also occur as an intercurrent malady during the
course of erysipelas and other blood diseases, such as pyæmia, small-
pox, glanders, rheumatism, etc. Sometimes it is the result of metasta-
sis in rheumatism, erysipelas, and the exanthematous fevers, in the
latter accompanied by retrocession of the exanthem. During infancy,
and even in the later months of fœtal life, peritonitis may occur from
other causes, chief of which is the puerperal infection consequent upon
the presence of an epidemic of puerperal fever, especially in lying-in
institutions, and gangrene and inflammation of the umbilical vessels,
and umbilical hernia; usually, however, ante-natal peritonitis is sup-
posed to be due to the presence of a syphilitic taint in the mother.
Pelvic peritonitis is a form of partial peritonitis, but it is, to a great
extent, ætiologically distinct from other varieties, and is of far more
828
A SYSTEM OF MEDICINE.
frequent occurrence. When occurring after parturition or abortion, it
may assume the features and course of puerperal peritonitis. It may
also occur from an extension of cellular inflammation in the pelvic
cavity; from an extension of gonorrhoeal inflammation, or ovaritis,
endometritis, or salpingitis; or from the escape of fluids through the
Fallopian tubes into the peritoneum after intra-uterine injections. A
case of this kind recently came under the writer's observation, when a
prostitute, suffering from a slight gonorrhoeal endometritis, fell into
the hands of a reckless and ignorant physician who injected a strong
solution of chromic acid, producing at once a violent metroperitonitis,
from which the woman barely recovered. A few weeks after recovery,
the original trouble not having disappeared, the same physician re-
sorted to the same injection, again resulting in a similar, but not so
violent, attack of inflammation. After this, occasional attacks of in-
flammation occurred, until death finally resulted about two years after
the first attack. Pelvic peritonitis most often arises from disorders of
menstruation, the result of imprudence during the presence of the
menstrual flow. It may be caused by bad uterine displacements, or
result from traumatic influences. In the latter list may be placed the
use of the uterine sound or sponge tent, which frequently gives rise to
pelvic inflammation. Dr. Barnes says he has seen fatal peritonitis
follow the simple application of nitrate of silver to the cervix uteri.
Pathology. The pathological character of peritonitis does not
differ essentially from that of the serous inflammations. The morbid
appearances are first an occurrence of hyperæmia, the capillaries being
distended, even to such an extent as to cause extravasations of blood
at various points. Subsequently, the redness consequent upon this
condition disappears, and the surface soon becomes cloudy from loss.
of its epithelium, and presents a velvety appearance, due to a prolifera-
tion of the connective tissue composing the peritoneum. The normal
secretion is arrested and an abnormal dryness occurs, which, however,
is soon followed by the exudation so characteristic of peritonitis, and
which never fails to appear, though it may vary greatly in character
and amount. First, an effusion takes place which forms a thin, trans-
parent covering upon the peritoneum, of a grayish-yellow color, readily
detached, and which loosely connects the various organs. In other
cases the deposit is a thicker, less transparent, yellow, croup-like mem-
brane, and, in the dependent parts of the abdomen, there is a moderate
amount of cloudy, flocculent serum.
Again, there may exist a great quantity of exudation. When the
abdomen is opened, an immense amount of turbid, flocculent fluid
escapes, while still more remains in the abdominal cavity. Besides
the membranous deposits covering the peritoneum, we find numerous
yellow clumps of coagulated fibrin which partly swim in the fluid,
partly sink, and collect in the dependent portions of the abdomen
DISEASES OF THE ORGANS OF DIGESTION.
829
}
(Niemeyer). Bauer endeavors to explain the varieties of effusion
which take place according to their physical and histological charac-
ters, with wide limits as regards quantity, which, he says, may vary
from a small amount in the true pelvis or in the spaces between the
intestines, to a quantity which is sufficient to press up the abdominal
viscera far into the thorax, displacing the heart, and compressing the
lungs into an entirely airless condition, thus producing death.
He speaks especially of three forms of effusion.
(1) The fibrinous effusion, with an exceedingly slight quantity of
fluid, hence, dry or adhesive peritonitis. This forms a continuous false.
membrane which invests the abdominal viscera, or sometimes, instead
of being continuous, occurs only in patches. This further results in
the formation of adhesive connective tissue which binds the various
organs and tissues together, producing permanent displacements, fix-
ing organs, and causing constrictions in organs which happen to be
included in the firm retraction of the new formation. It may also
produce a whole series of disturbances in function, or, later, give rise
to incarceration, twistings, constrictions and a fresh inflammation of
the peritoneum. These layers of false membranes often include fluid;
frequently they are pigmented, and occasionally concretions occur
imbedded in thick connective tissue, the result of calcification of the
effusion.
According to Niemeyer,† this form of exudation is chiefly found in
peritonitis due to injuries or to the propagation of inflammation from
neighboring organs.
(2) Bauer next mentions the serous and sero-fibrinous effusion, where
it approaches in its characters pure ascitic fluid; it is yellowish-green
or milky-white, turbid, and flakes and separate pieces of false mem-
brane are suspended in it. The quantity may be enormous, especially
in terminal peritonitis supervening on ascites, but in other cases it is
much less. After the fluid has become absorbed, all further alterations.
proceed as with the fibrinous variety. Niemeyer holds that this form
of exudation is more frequent in peritonitis from perforation, or de-
pendent on infection, particularly puerperal, and lastly in the so-called
rheumatic peritonitis.
(3) Purulent effusion. This may be either a thickly fluid pus, or a
very mobile, purulently turbid fluid, and is found in the most depen-
dent parts, unless sustained by matting and adhesions. This form
may be associated with suppuration of the peritoneum consequent
upon ulceration of the same, or as a result of long contact with masses
of pus, or from perforations and escape of purulent or decomposing
matters into the peritoneal sac. It thus constitutes the most frequent
variety of exudation met with. By admixture with gastro-intestinal
* Ziemssen, vol. viii., page 235.
† Niemeyer's Practical Medicine, vol. ii., page 640.
830
A SYSTEM OF MEDICINE.
contents the pus may present a foul, discolored appearance, and fecu-
lent smell, and gases may be found occupying the free abdominal cavity.
There is also more or less admixture of blood, as is, indeed, the case
with all varieties.
In cases of recovery, absorption of the fluid takes place rapidly, and
suspended particles, flakes, coagula, or pus, undergo fatty metamor-
phosis, become fluid, and are absorbed; but partial thickenings and
adhesions of the peritoneum always remain. In partial peritonitis
the changes are similar, only limited to the part involved. If the ex-
udation be of the fibrinous variety, the process often results in adhe-
sion of the inflamed parts. If the exudation be serous or sero-fibri-
nous, portions may become capsulated and run the usual course.
The changes of chronic peritonitis are similar to those of the acute
form, being usually the result of a protracted course of the same.
There is often little or no fluid exudation, and when present, it is not
abundant, and has a purulent or semi-purulent form. The chief char-
acteristic is the formation of a false membrane, which may be general
or only exist in local bands. The intestines usually adhere in globular
or shapeless masses, and between the various convolutions there are
cavities filled with serous, purulent, or bloody fluid, the purulent often
being converted into a cheesy mass. Occasionally a part of the false
membrane undergoes a calcareous transformation; or it may become
soft, friable and granular, preparatory to absorption, or may be con-
verted into connective tissue.
In puerperal peritonitis, according to Lee,* the appearances of in-
flammation are sometimes confined to the uterus, but they are much
more generally extended to other organs. The lymph is mostly thrown
out in thicker masses upon the uterus than in any other situation, and
this viscus seems to suffer in the greatest degree. In the sub-serous
cellular tissue, serum and pus are often deposited. The cellular tissue
surrounding the vessels of the uterus where they enter or depart from
the organ, and that connecting the muscular fibres, is often surcharged
with serous and purulent fluid. The peritoneum becomes thick and
vascular, more especially where it invests the uterus and pelvic viscera,
and sometimes, where the malady is intense, the serum is mixed with
blood, and pus is found in the pelvis. When death has rapidly fol-
lowed, the lymphatic exudate is semi-fluid, or the surfaces which
have become agglutinated are readily torn asunder. The Fallopian
tubes and ovaries are sometimes filled with pus or blood (Wardell).
In pelvic peritonitis, the changes are not essentially different from
those in general peritoneal inflammation. The most characteristic
feature is the deposition of lymph and serous or purulent fluid into
the cellular tissue about the uterus, which, in the second stage, im-
parts to the sense of touch a feeling as if hot lead had been poured
* More Important Diseases of Women, page 24.
DISEASES OF THE ORGANS OF DIGESTION.
831
into the tissues and allowed to cool, rendering the roof of the pelvis
hard and unyielding. The uterus is usually displaced, and its ap-
pendages seem solidly fixed, being held immovable by the surround-
ing elements. The subsequent processes of absorption or purulent
degeneration and the formation of adhesions do not differ from the
same in other varieties of peritoneal inflammation.
Symptomatology.-In idiopathic peritonitis the attack is usually
abrupt, being ushered in by a chill, followed by intense fever and very
severe local pain and tenderness. The pain is of a burning or lan-
cinating character, and may, from the start, be distributed over the
entire abdomen, or, at first, be circumscribed, and extend gradually.
The slightest touch, deep inspirations, and the acts of coughing or
sneezing cause intense exacerbation; at times the pain assumes the
character of spasm or colic. Usually the patient lies on his back, if
the peritonitis is general, with the thighs flexed on the pelvis, and the
shoulders elevated, in order to prevent pressure of the muscles on the
tender peritoneum, though this decubitus is by no means constant.
The respiration becomes superficial and rapid, to avoid motion of the
diaphragm; in other words, the breathing is costal. Every cough and
every full respiratory movement is most anxiously avoided, and every
motion of the body causes severe pain. The aspect of the countenance
soon becomes altered in a remarkable manner; the eyeballs are sunken
and are surrounded by a bluish-black ring; the face assumes a hollow,
withered expression, the nose becomes pinched, the cheeks fall in, the
lips become thin and bluish, the skin is cold and covered with a cold
sweat, the voice is husky, and the expression of pain and anxiety is
vividly depicted. These symptoms of collapse, according to Bauer,
are generally connected with the quantity of the effusion and the
severity of the vomiting, which is rarely absent. This usually sets in
early, the articles vomited being first food and gastric mucus, and then
biliary matters from the duodenum, and, later, feculent matter, owing
to occlusion of the intestines. The acts of vomiting occasion great
pain. In the latter part of the course of the disease the contents of
the stomach are apt to be ejected by regurgitation rather than by
vomiting. The abdomen soon becomes distended and tense, generally
in a great degree, and remains so during the course of the disease.
This distension is first due to the presence of gas in the intestines, the
subsequent extreme tympanitis being supposed to result from a paresis
of the muscular fibre of the bowel, allowing an expansion of the con-
tained gases, and at the same time retarding their escape. The tym-
panitic percussion-sound is obtained most over the course of the colon,
and over the abdomen in general, except in the most dependent parts
where the collection of fluid gives rise to dulness varying with the
changes of position of the patient. The distension of the abdomen
presses upwards, encroaching upon the diaphragm, and compresses
832
A SYSTEM OF MEDICINE.
the lungs, giving rise to most distressing symptoms of dyspnoea and
rapid respiration, while the disturbance of the circulation thus caused
may give rise to cyanotic symptoms.
Obstinate constipation is usually present, arising from paralysis of
the muscular coat of the intestines. At the same time, paralysis of
the sphincter is sometimes present, allowing the escape of fæcal matters
by mere pressure upon the abdomen. This has been particularly ob-
served in puerperal peritonitis, where a serous diarrhoea often occurs
from transudation, which may also exist where there is present some
coincident intestinal disease, tuberculosis, or any form of septicemia,
whether connected with the puerperal state, or not.
occur.
Painful urination is present; the desire to urinate is frequent, and
the quantity of urine passed is very small. Complete retention may
In many cases there is a distressing hiccough, the tongue is
generally coated, and there is a complete loss of appetite, and great
thirst. The pulse is quick, small, and wiry, ranging from 120 to 140
per minute; the temperature from 103° to 105° F., or even higher.
On approaching collapse, the pulse rises to from 160 to 200, but the
temperature falls below normal.
The expression of the countenance is that of extreme anxiety and
distress. Sometimes the upper lip is elevated and drawn tight over
the teeth, as is seen in no other disease. The intellect generally remains.
clear, but finally becomes clouded, the patient growing apathetic and
delirious towards the close of the disease.
The course of peritonitis is rapid, and the mortality very great. If,
as sometimes occurs, the malady takes a favorable course, the pain,
tympanitis, and fever generally subside, the respiration becomes freer,
and the patient may recover rapidly, though often adhesions remain.
which may produce habitual constipation for life. If peritonitis arises
from perforation, death may be expected within two or three days.
In idiopathic peritonitis death occurs usually in the course of five or
six days, but may be delayed until the middle of the second week.
In case death does not occur within this time, nor improvement set
in, the disease usually assumes a chronic form, all the symptoms
moderate, the pain, fever, and tympanitis partially subside, but the
effusion persists, dulness on percussion becomes more distinct, and an
increasing resistance is observed over the dull spots. Sacculations are
formed with dense membranes, which cause considerable opposition
to the absorption of the inclosed effusion, and which act as incentives
to new inflammation in the intervening spaces. Thus we may have
present at the same time the symptoms of existing effusion and its
metamorphosis, and those of pus-inflammation. These sacculations
appear like irregular tumors, and give the abdomen a nodular and
unsymmetrical appearance. Sometimes the capsulated exudation be-
comes purulent and gives rise to symptoms of abscess, together with
DISEASES OF THE ORGANS OF DIGESTION.
833
chills, fever, sweat, and other indications of septic poisoning. Usually,
in the chronic form, an obstinate constipation alternates with a profuse
diarrhoea, which greatly exhausts the patient. The urine is passed
in small quantities, which slowly increase if absorption of the fluid
takes place. The patient gradually emaciates, the muscles become
soft and flabby, the skin dry and scaly. Edema of the lower extremi-
ties sets in, and death from exhaustion occurs in the fifth or sixth
week. Sometimes ulceration and perforation of the peritoneum occurs,
which is marked by a sudden increase of the temperature and pulse,
and symptoms of an abscess pointing externally soon appear, or, in
more fortunate cases, the abscesses perforate the intestine, and their
contents are discharged per rectum. Such patients either make a very
slow convalescence, or finally die from exhaustion. If reabsorption of
the exudation takes place in chronic peritonitis, the convalescence is
always very slow, and remaining adhesions leave various contractions
and distortions of the pelvic viscera, which are usually the sources of
lifelong and severe suffering.
In partial peritonitis the symptoms of a primary disease from which
the former extends may precede the peritoneal symptoms, though
often the primary disease remains latent until the peritoneal inflam-
mation is developed. The symptoms are first those of general peri-
tonitis, but they rapidly become localized. The pain and the degree
of tenderness often depend largely on the extent and rapidity of the
inflammation, which is oftener subacute than acute in its character.
Some of the symptoms of general peritonitis may be entirely absent,
as is notably the case with the vomiting and tympanitis, which, if
present at all, are only so in a comparatively mild degree. In mild
cases the symptoms may rapidly disappear and the patient entirely
recover. More often, however, the local symptoms, though apparently
subsiding, remain, and percussion over the spot gradually becomes
duller, the resistance of the abdominal walls more decided, and a more
or less defined tumor makes its appearance, which suppurates, and may
discharge externally or follow the course of a capsulated abscess in
general peritonitis. This condition more often follows the partial
peritonitis consequent upon an inflammation and ulceration of the
cæcum and vermiform process.
Pelvic peritonitis presents some symptoms peculiar to itself. An
attack may be preceded for several days by pelvic uneasiness and
weight, but quite as often it is ushered in with the chill, fever, and
pain characteristic of the other varieties. The pulse and temperature
are variable, sometimes being nearly normal and at other times very
high, and sometimes fluctuating between the two conditions. The
symptoms of local tenderness, tympanitis, vesical irritation, nausea,
etc., do not essentially differ from those occurring in other varieties of
partial tympanitis.
VOL. I.-53
834
A SYSTEM OF MEDICINE.
The subacute and chronic forms are often quite barren of symptoms,
and frequently pass unrecognized. The patient may only complain.
of local discomfort and weight, aggravated at the menstrual period,
with more or less difficulty of locomotion, and a general feeling of
weariness, which symptoms are often attributed to other causes. Physi-
cal examination in the first stage only reveals the usual tenderness,
and a sensitiveness upon pressure in the vaginal cul-de-sac, and upon
attempting to push up the uterus. This is sometimes the extent of
the physical signs, but if the disease progresses either fluctuation or a
tumefaction may soon be observed at the side of the uterus or in the
posterior cul-de-sac, the part being extremely sensitive to touch.
Should pus form, it will be discharged and the tumefaction disappear,
but more often the effused lymph becomes organized and leaves a
hard, resisting tumor which causes displacement of the uterus, and
disappears slowly. The disease may run its course in a few weeks,
and then disappears entirely. At other times it assumes a chronic
character, the patient suffering from acute symptoms only at the men-
strual periods. Frequently the uterus is permanently displaced by
the remaining adhesions.
Infantile peritonitis rarely occurs idiopathically, and when it does, or
when it follows exanthematous diseases, or occurs during an epidemic
of puerperal fever, it presents but few features essentially different from
peritonitis in adults. The skin usually presents a dirty-yellow color,
and in the last stage becomes cyanotic and icteric. Vomiting occurs
with less uniformity than in adults, but the child refuses the nurse
from the beginning, as the act of sucking increases the pain in the
abdomen. A watery diarrhoea is present instead of the constipation
which is found in adults. The disease may run a very rapid course
and terminate fatally in 24 or 48 hours, though in older children it may
continue for several days, and occasionally, though seldom, assume a
rather chronic course.
In ante-natal peritonitis the symptoms are too indefinite to be relia-
ble, especially if death occurs before birth. Sometimes the child is
born with an intensely distended and painful abdomen, with oedema.
of the lower limbs, and with jaundice, thus suggesting at once a dis-
eased peritoneum. Such cases nearly always die within a few hours
or, at most, days.
Puerperal peritonitis offers some peculiarities distinct from those
varieties which occur independent of the puerperal state. The symp-
toms usually appear within five days after confinement, though in
exceptional cases the interval may be much longer. The patient first
complains of pain, and experiences a chilliness which soon gives place
to hot skin, quick pulse, and rapid respiration. The pain is charac-
teristic, and resembles the pain of general peritonitis, but neither pain
nor tenderness is uniformly present. The abdomen enlarges and
DISEASES OF THE ORGANS OF DIGESTION.
835
becomes tympanitic much more rapidly than in general peritonitis,
probably on account of the recent and prolonged distension of the
uterus and abdominal walls, and their present relaxed condition. The
lochia are diminished in quantity, or entirely suppressed. The secre-
tion of milk does not take place, or if it has already done so, it is sup-
pressed, and the mammæ become small and flaccid. Otherwise the
symptoms and course of this form do not vary essentially from those
of general peritonitis.
Varieties.-Peritonitis may occur in either an acute or chronic
form, and be either general or partial, as previously defined. The term
perforative peritonitis has been given to that variety in which there has
been a positive solution of continuity of the membrane, a rupture of
the peritoneum having taken place either from suppuration, ulcera-
tion, or from mechanical violence.
Erysipelatous peritonitis occurs as a sequel or complication of the
exanthem in adynamic fevers and in puerperal peritonitis, and is
supposed to originate in a general blood change, holding a close rela-
tionship to that present in pyæmia. In such cases the inflammation
is very extensive, intense, and rapid in its progress, the products being
remarkably non-plastic, consisting chiefly of a purulent-looking fluid
which may occur in great abundance. The symptoms are very severe
and of a low type. Adynamic peritonitis includes all forms in which
there is a rapid tendency towards a typhoid condition, the tongue being
dry and brown, the teeth covered with sordes, and low nervous symp-
toms predominating. Puerperal peritonitis includes all cases which
occur during the puerperal state. It must, however, be borne in mind
that here reference is not made to puerperal fever in general, for this
does not necessarily include a peritoneal inflammation, but only to
that form of puerperal fever which is characterized by peritonitis with
or without pyæmia. The latter is the form which most often occurs
sporadically, but there exists such doubt as to the nature of possible
contagion that great caution should be entertained even in these cases.
Traumatic peritonitis results from mechanical injury. Infantile peritoni-
tis occurs during infancy and childhood, and even during intra-uterine
life. This variety has usually been made to include tuberculous perito-
nitis, the consideration of which will be found in the chapter on tuber-
cles of the peritoneum. Partial or circumscribed peritonitis is often
designated according to the locality affected, the name indicating the
viscus whose peritoneal investment is involved, as perihepatitis, peri-
splenitis, perimetritis, perityphlitis, etc. Pelvic peritonitis denotes an in-
flammation limited to the peritoneal covering of the female pelvic
viscera, and is of a very common occurrence; its presence is often
overlooked, its symptoms being referred to other causes.
Diagnosis.—It is sometimes very difficult to establish the diagno-
sis of acute peritonitis. However, the mode of onset, the great pain
A
836
A SYSTEM OF MEDICINE.
@
and excessive tenderness on pressure, together with the tympanitis, the
posture of the patient, and, often, the symptoms of pyæmia, will usu-
ally serve to differentiate it from other inflammatory or hysterical af-
fections.
Enteritis is less intense in all its manifestations. Colic lacks the con-
tinuous pain, tympanitis, high temperature and pulse, and muscular
rigidity of peritonitis. In rheumatism of the abdominal muscles there.
will usually be evidence of rheumatism in some other part of the
system; the pain is limited to the muscles, deep pressure does not in-
crease it, and the constitutional symptoms do not indicate a severe
disease. Neuralgic conditions of the abdomen, occurring in hysterical
women, and complicated with hyperæsthesia of the skin, often simulate
peritonitis. Frequently, in such cases, there is more or less tympanitis,
and the patient may assume the dorsal decubitus with the thighs and
knees flexed; but there is usually present the ordinary hysterical his-
tory, an absence of fever and of muscular rigidity, and firm, deep pres-
sure is well borne, and may even afford relief, while light pressure is
unbearable. In the passage of gall-stones there is usually great sensi-
tiveness in the right hypochondrium, but the pain is paroxysmal, and
there is an absence of tympanitis and of the constitutional symptoms
of peritonitis, and, moreover, all trouble ceases as soon as the stone has
passed. In cases of peritonitis dependent upon perforation, in cases
in which the conditions leading to perforation have never been recog-
nized, it is often a difficult matter to establish a correct diagnosis.
Under all circumstances, a correct idea of the primary disease which
has given rise to the peritonitis makes the diagnosis a comparatively
easy matter. In the puerperal state, severe after-pains are sometimes
mistaken for peritonitis.
It will be observed, however, that after-pains always occur with a
firmly contracted uterus, while in peritonitis the uterus is relaxed;
after-pains come on immediately after delivery, and wear away gradu-
ally, while peritonitis comes on later, and the pain becomes more and
more intense, and we have fever and other constitutional symptoms
which are seldom present with after-pains. Subacute and chronic.
peritonitis are often difficult of recognition, especially when not pre-
ceded by the acute form. They are most likely to be confounded with
symptoms resulting from stasis of the portal vein, especially ascites,
cirrhosis of the liver being the disease which it is most often necessary
to exclude. In the latter, the jaundice, enlarged spleen, clay-like stools,
dark-colored urine, and normal temperature and pulse, together with
the diagnostic symptoms of ascites, will be sufficient to establish its
presence. Simple chronic peritonitis cannot always be distinguished
from the tuberculous form, especially when it occurs, as it sometimes
does, in patients suffering with tubercular diseases in other organs.
The aspirator or the exploring needle in the tubercular form will show
*
DISEASES OF THE ORGANS OF DIGESTION.
837
more or less hæmorrhagic admixture in the effusion. Partial peri-
tonitis, being generally connected with an affection of the parts covered
by the inflamed portion of the membrane, is usually readily distin-
guished. If the inflammation is situated over the liver or spleen we
may hear a friction sound, the presence of lymph causing roughness
of the opposing surfaces. In such cases we usually get the costal res-
piration, so characteristic of general peritonitis. Pelvic peritonitis
may be confounded with pelvic cellulitis. It must be remembered
that the latter will probably only occur after parturition, abortion, or
an operation on the pelvic viscera, while peritonitis results from an
entirely different class of causes. If the inflammation results from
the extension of gonorrhoeal disease it is safe to locate it in the cellular
tissue rather than in the peritoneum. Pelvic hæmatocele is more sud-
den in its onset, and is chiefly characterized by the symptoms of great
loss of blood with which there are no inflammatory signs. The tumor
rapidly assumes a larger size than any enlargement connected with
peritonitis, and is at first soft, gradually becoming hard. Hæmatocele
may excite peritoneal inflammation, after which a diagnosis is more
difficult. Thomas* holds that fæcal impaction is a frequent complica-
tion of pelvic peritonitis, and, often remaining after the inflammation
has passed away, gives rise to the belief that the latter is still present.
I am confident, however, that this is seldom the case when opium has
not been freely used to relieve the pain consequent upon the peri-
tonitis.
Prognosis.—Acute general peritonitis is at best a grave malady,
and the prognosis should always be guarded. Cases which arise from
the extension of simple inflammation of the abdominal and pelvic
viscera by contiguity of tissue, or cases of traumatic origin, offer the
most favorable prognosis, while, on the other hand, the gravest cases
are those which are associated with pyæmia and other forms of blood-
poisoning, including puerperal peritonitis. The next gravest in char-
acter is perforative peritonitis, and I question if it should not be
ranked as the most uniformly fatal, though recovery is not impossible,
provided the opening be small and closure be quickly effected by the
exudation of lymph and the formation of adhesions around it.
Death in fatal cases usually occurs in five or six days. Unfavorable
symptoms are: rapid, weak, and intermittent pulse, increasing pros-
tration, hurried and more shallow respiration, hiccough, cool and
clammy surface, and cold legs and feet. On the other hand, favorable
symptoms are: a remission of the pain and tenderness, diminution
of the tympanitis and muscular rigidity, with a gradual return to the
normal of the pulse, respiration, and temperature. At best, conva-
lescence is slow, often extremely so, considerable tenderness remain-
* A Practical Treatise on the Diseases of Women, by T. Gaillard Thomas, M.D.,
page 477.
838
A SYSTEM OF MEDICINE.
ing, and paroxysms of colicky pains occurring frequently for some
time. The prognosis of chronic non-tubercular peritonitis is consid-
ered unfavorable, though it may require months, and even years, to
bring about a fatal issue. According to Galvagni the prognosis is
more favorable when the effusion is serous, especially in children;
less favorable in the fibrinous forms, and least favorable in the puru-
lent.
The results of homoeopathic treatment have shown a considerable
reduction in the mortality of both the acute and chronic forms of
peritonitis, and it is considered by many that the fibrinous bands and
adhesions which are so apt to remain after peritonitis, often causing
the patient lifelong misery, may be removed by the potent influence
of homœopathic remedies.
The prognosis in partial peritonitis is so entirely dependent upon
the nature and extent of the disease with which it is associated, that
while generally we may expect a favorable issue, this is not by any
means an invariable rule. Of course, when there is a purulent collec-
tion which does not discharge externally, bad results may be antici-
pated.
Treatment. The prevention of peritonitis may only be accom-
plished by the avoidance of the agents by which it is propagated. It
is, however, only in the treatment of the puerperal variety that the
physician has opportunities to adopt preventive measures. During
the prevalence of an epidemic, either in or out of lying-in institutions,
it is of much importance that the room be light and airy, the temper-
ature kept at about 60° F., and the most scrupulous cleanliness be
observed. A physician having one or more cases of erysipelatous
disease should under no circumstances consent to attend a fresh ac-
couchment.
Patients suffering with acute peritonitis, whether puerperal or not,
should be kept in a well-ventilated apartment, with a uniform tem-
perature of 60° F. They should lie on a soft mattress, feather-beds
being entirely proscribed. The coverings should be light, and fre-
quently it may be found necessary to keep the covers from coming in
contact with the abdomen by means of barrel-hoops or some other
suitable contrivance. For the violent thirst, small draughts or sips of
fresh water may be allowed, but it will be found that small lumps of
ice placed in the mouth will answer equally well, and not excite vom-
iting as readily as the water does.
-
When convalescence begins, the diet should be of mild unstimulat-
ing character, solid food being avoided on account of the bulky fæcal
residuum. Soups, especially beef broth, are desirable; also arrow-
root, tapioca, and other farinaceous articles, which, unless there is
much exhaustion, should precede the animal broths. After a time.
lean meat may be allowed, but it should be used cautiously, as should
DISEASES OF THE ORGANS OF DIGESTION.
839
་
also fruits and vegetables, which tend to produce flatulence. If at any
time the patient shows signs of rapid exhaustion, resort should be had
at once to the use of stimulants, small quantities of good wine or of
brandy and water being most desirable. In chronic varieties, gentle
exercise, either by carriage or boat-riding, is often beneficial, though
it must not be carried to the point of fatigue. When the patient can
endure the removal, it is sometimes wise to give a change of air and
scenery by sending them to the seaside or some summer resort, or
even, if desired by the patient, by allowing an ocean voyage. In the
acute varieties, the habit of blood-letting and the use of opium and
cathartics, which are the chief features of treatment by the old school,
should be persistently avoided as unjustifiable and positively injurious.
The application of the appropriate homeopathic remedies will prove
far more effectual. Indeed they could not well prove otherwise, as the
mortality statistics of peritonitis under old-school treatment show an
average fatality of about seventy-five per cent., while the remaining.
twenty-five per cent. suffer more or less for years, and sometimes
through life, from the sequela.
Therapeutics.-Aconite is most often indicated in the first stage of acute at-
tacks, especially when resulting from cold or from drinking cold water when overheated.
The skin is hot and dry, the temperature high, the pulse hard, full, and frequent, and
the respiration short and quick. The patient is extremely anxious and restless. The
abdomen is swollen, burning hot, and sensitive to the touch. There is great thirst, much
vomiting, the urine is scanty, scalding hot, and red or dark colored; after confinement
the lochia and milk are suppressed, and there are sharp cutting pains, worse from
pressure, or when lying on the right side.
Belladonna ranks next in importance. It is frequently indicated from the
first, especially in the puerperal variety. The pulse is full and strong; there is much
throbbing of the carotid arteries; the face is flushed, and the eyes brilliant and pro-
truding, and there may be delirium. The abdomen is painfully distended, with much
heat and burning; cutting, colicky pains, worse from the slightest motion or contact.
This remedy is often indicated when there are complications with metritis or perity-
phlitis. After confinement, when the lochia are hot and offensive or suppressed, and
violent after-pains occur, Belladonna is the chief remedy, often preventing peritoneal
inflammation.
Bryonia follows Aconite or Belladonna after the fever has relaxed and effusion
has taken place; it promotes absorption. It is indicated by the stitching, lancinating
pains in the bowels, worse from the slightest motion. There is great thirst for large
quantities of water; the mouth, lips, and tongue are very dry; the tongue is thickly
coated white; there is considerable nausea from motion, and obstinate constipa-
tion. It is especially useful when the diaphragm is involved in the inflammatory
action.
Veratrum album is indicated when there is much vomiting and diarrhœa;
violent colicky pains; coldness of the skin; cold sweat, especially on forehead; sunken
features; small and weak pulse, and great restlessness, anxiety, and exhaustion.
Mercurius corrosivus.-Purulent exudations; creeping chills, surface cold,
and covered with perspiration, which affords no relief; foul odor from the mouth; dis-
tended and painfully sensitive abdomen; mucous stools, with persistent tenesmus and
violent burning and cutting pains; oedematous swelling of the feet; great weakness and
emaciation. Is especially useful in the various forms of partial peritonitis, with a ten-
dency to the formation of abscesses.
Sulphur, like Bryonia, promotes absorption of the exudation, and often follows
that remedy well. Sulphur is preferable to Bryonia in chronic cases and in scrofulous
subjects. There is great weakness and deficient reaction. When carefully selected
remedies have failed to do any good, or have only brought the case to a certain point,
at which it persistently remains, Sulphur should be selected.
840
A SYSTEM OF MEDICINE.
Arsenicum album is of great value in cases of the asthenic type, or in
which the exuded fluid is copious and persistent. There is a sudden sinking of
strength; great restlessness and anxiety; hippocratic countenance, violent burning and
cutting pains in the abdomen; constant thirst, drinking often, but little at a time;
vomiting, and sometimes diarrhoea. All symptoms are worse after midnight.
Calcarea ostrearum is a remedy of much importance in tubercular periton-
itis, and in the simple chronic variety, when occurring in scrofulous persons, especially
in children of a leucophlegmatic temperament. In such the abdomen is hard and much
distended, and the mesenteric glands are hard and swollen.
Opium is an efficient remedy for the paralytic condition of the bowels which
remains after the disappearance of the exudation, producing obstinate constipation.
Nux vomica.-May be needed to complete the cure of the constipation, and to
remove irregularities of digestive functions which may remain.
The following remedies may be consulted, as possibly useful: Apis,
Calcarea phos., Calcarea iod., Cantharides, Carbo veg., Cinchona, Colocyn-
this, Lachesis, Nitric acid, Phosphorus, Rhus tox., Sulphuric acid.
The most valuable of the auxiliary measures is the application of
hot fomentations over the abdomen, or of hot poultices, made from
corn or linseed meal. The latter will retain the heat for a long time,
but must be made very thin, and should be covered with cotton. Many
physicians contend that in the first stage ice or ice-cold applications
should be used, warm applications being useful only after the fourth
or fifth day. It is claimed that the cold not only tends to reduce the
inflammation by withdrawing heat, but that it also excites peristalsis
and allays pain.
It is further asserted that by the local reduction of temperature the
gas in the intestines is condensed. The fact, however, that excessive
reaction so often follows the use of cold applications, seems to retard.
their employment and to render the hot applications more desirable.
Probably it is safest to allow the patient's subjective condition to be
the guide, using hot or cold applications as most agreeable to the pa-
tient. Often, in the first stages, as in other inflammations, the wet
pack is of great benefit, but such a measure should not be adopted
unless it can be conducted by an experienced nurse, an important
item in the application of all auxiliary treatment. As a rule, it is
unwise to evacuate the serous or sero-purulent effusion which may
occur, unless it becomes so excessive as to threaten life, in which case
it may be withdrawn by the aspirator or by a small trocar and canula.
TUBERCLES OF THE PERITONEUM.
BY A. C. COWPERTHWAITE, M.D., PH.D.
The frequency of tubercular depositions in the peritoneum is only
second to that of the same in the pulmonary structures and in the
mesenteric glands. If only existing locally, in connection with tuber-
cular ulceration of the intestines, occupying a space on the serous.
membrane corresponding to the diseased portion of the bowel, they
DISEASES OF THE ORGANS OF DIGESTION.
841
may give rise to very little disturbance, and not be recognized during
life. When, however, tubercles are developed on the serous surface
without local cause, and from the condition of system which gives rise
to similar deposits in other organs, they induce characteristic and im-
portant symptoms which are of the utmost clinical interest.
This condition is often described as tubercular peritonitis, owing
to the local inflammation induced by the presence of the tubercles,
and was formerly considered a variety of peritoneal inflammation.
Tuberculosis of the peritoneum may occur in all ages, but is de-
cidedly more frequent in children over five years of age, and is almost
invariably associated with tubercular deposits in other organs, to which
it appears to be secondary.
Pathology. As has been observed, tubercles of the peritoneum
rarely exist alone, but are associated with a general tubercular condi-
tion, the lungs being usually involved in the same process, as may be
the intestines, mesenteric glands, pleuræ, kidneys, liver, spleen, and
even the brain, uterus, and other organs and glandular tissues. The
most frequent seat of the tubercles is upon the attached surface of the
peritoneum where they are formed from the connective tissue, which
proliferates to a remarkable extent, giving an extensive fibrous growth
in which the tubercles are abundantly deposited; at the same time,
an adhesive exudation takes place, giving rise to false membranes,
which again become the seat of the tubercular deposits. Every por-
tion of the peritoneum is liable to the disease, whether visceral, parietal
or omental, but it is rare that tuberculization of all these surfaces occurs
in the same case. The individual character of the tubercles may vary,
as it does in other organs and portions of the body. They are spherical
or lenticular in shape, and are usually very small, sometimes so minute
as to be scarcely visible, but may be as large as a poppy-seed; they
present an opaque white, or grayish, or yellowish appearance, accord-
ing to their age. Sometimes, as they advance in age, they assume the
form of globular masses which are of a cheesy consistency, and present
a yellowish color. Frequently these tubercular masses, together with
the inflammatory products which invest them, are so large that they
can be felt through the abdominal walls. The formation of the deposit
does not always occur simultaneously on different portions of the mem-
brane, but generally it may be found in all stages of development, the
new and old tubercles existing in close proximity, the one just forming,
while the other is undergoing its retrograde metamorphosis. This pro-
cess may continue uninterruptedly, or periods of repose may occur
wherein no new development takes place. An effusion of serum gene-
rally occurs into the peritoneal cavity, which is of a greenish-yellow
color, and turbid in its appearance. Often this is mixed with the
coloring matter of the blood, which has been more or less decomposed,
and which gives it a brownish or brownish-red color. When periods
842
A SYSTEM OF MEDICINE.
of cessation from tubercular development occur, this effusion becomes.
absorbed, only to reappear with the fresh outbreak of new formations.
The local appearances of inflammation occur in greater or less degree,
and are usually in proportion to the amount of the serous effusion, the
quantity of which depends upon the extent of the inflammation. Some-
times, owing to the adhesive connections which are established with
the intestines and the consequent distortions of the bowels, ulceration.
of the mucous membrane may be established, resulting in hæmor-
rhage into the peritoneal cavity, and even perforation of the bowel
from without.
Symptomatology.-The characteristic symptoms of peritoneal
tubercles are mainly attributable to the inflammatory condition. These
are modified and often overshadowed by the symptoms of constitu-
tional tuberculosis, affecting different portions of the body, some of
these local lesions preceding the tubercular manifestation in the peri-
toneum. Thus it occurs that the symptoms and course of tubercular
disease of the peritoneum vary greatly in individual cases, it being
almost impossible to establish any definite aspect by which the local
character of the affection may be readily recognized. Kaulich * de-
scribes three varieties, which, however, are necessarily indistinct, often.
passing from one into the other. The first variety represents the acute
cases in which the symptoms often simulate the ordinary remittent.
fever or enteric fever. The patient experiences febrile symptoms, pain
in the limbs, and malaise. The abdomen, either at a circumscribed
spot, or over a larger area, becomes hard, tumefied and tender, and
the patient complains of pain in it. With this, there is usually more.
or less vomiting, constipation and meteorism, with the usual indications
of a partial peritonitis. After a short time these symptoms may dis-
appear, save the circumscribed abdominal tumefaction and hardness
which remain. The same process is soon after repeated, another por-
tion of the abdomen being attacked; these attacks continue, with longer
or shorter intermissions, until, finally, almost the entire abdomen be-
comes involved. The parietes are drawn in, hard lumps or knuckles
are felt over the abdominal walls, and between these fine, cord-like,
fibrous thickenings, but no fluid effusion. The patient soon emaciates,
the functions of nutrition become impaired, vomiting and constipation.
continue, but no acute symptoms occur. Sometimes symptoms of a
typhoid character supervene, and the patient gradually succumbs;
but generally, death results from the occurrence of tuberculosis in
other organs. It cannot be said that this is the constant character of
the acute variety, for frequently the disease commences with more de-
cidedly acute symptoms, rapidly followed by fluid effusions, and general
constitutional disturbance, the disease gradually assuming a chronic
form.
* Klinische Beiträge zur Lehre von der Perit. Tuberkulose. Prag. Viertelj., ii., 36.
DISEASES OF THE ORGANS OF DIGESTION.
843
Kaulich's second variety comprises the disease in its various chronic
manifestations, either where it follows the acute stage or where, as is
more often the case, it creeps on insidiously, the patient for a long
time only recognizing weakness and the progressive distension of the
abdomen. There is little, if any, pain in the abdomen, the principal
complaint being a sensation of fulness and tension. The symptoms,
as a rule, are almost identical with those of ordinary chronic peritoni-
tis. After a time ascites become the most prominent feature, causing
great abdominal distension, although the latter is often partially due
to the coexisting meteorism. Frequently, tumors formed by the coils
of the distended intestines are seen projecting in the upper part of the
abdomen. The usual pressure of the ascitic fluid upon adjacent or-
gans occurs, and produces dyspnoea and disturbance of the functions
of the liver and other organs involved. At this stage, tuberculosis of
the lungs and other organs becomes manifest, if, indeed, it has not
constituted the primary disease. The symptoms of general tubercu-
lar disease may be so associated with the local manifestations as to
greatly aid in the diagnosis, or, again, may so preponderate as to en-
tirely overshadow the latter, and render the diagnosis obscure. Some-
times, in these cases, an effusion of blood takes place into the peritoneal
cavity, which is indicated by symptoms of collapse; or tubercular per-
foration of the intestine may occur, and then death rapidly follows.
These are the two varieties which particularly claim attention, but
Kaulich designates a third, which really comprises the same class of
cases, only characterized by a temporary subsidence of the general
symptoms with decrease of the effusion and an improvement of the
general health, lasting for an indefinite time, to be followed by another
attack similar in its symptoms and course.
As has been stated, the course and character of the disease are quite
indefinite, no two cases commencing precisely alike or retaining the
same peculiarities throughout. The symptoms of fever, pain, and ten-
derness are not uniform in their character, and the effusion may vary
greatly both in quantity and quality, as well as in its external mani-
festations. Many cases, entirely anomalous, have occurred, the char-
acter of the disease only having been recognized after death. Some-
times death results in a few weeks, but more often the disease lasts for
months and even years.
Diagnosis. Enough has already been said to indicate the diffi-
culty in diagnosis which may arise from the complication of other or-
gans in the tubercular disease. If it is possible to exclude the presence
of the tuberculosis of the lungs, heart, or kidneys, we may then not be.
certain as to the presence of cirrhosis of the liver, which, in many re-
spects, is quite identical in its symptomatology with tubercles of the
peritoneum. This latter disease, however, usually occurs in persons.
who have been addicted to strong drink, the tubercular dyscrasia is
844
A SYSTEM OF MEDICINE.
also absent, the abdomen is less painful and less sensitive to pressure,
the spleen may be enlarged, the pulse and temperature not affected,
at least not continuously, there is less vomiting, emaciation is not so
marked, and there is often a collateral dilatation of the veins, which
does not occur with peritoneal tubercles. From carcinoma of the peri-
toneum, or of other organs, we may usually distinguish tubercles of the
peritoneum by the absence of the cancerous cachexia and by the local
manifestations of a cancerous growth ordinarily present in such cases.
The differential diagnosis from chronic peritonitis usually depends
upon the presence of the constitutional symptoms of tuberculosis, but
since simple chronic peritonitis may occur in tubercular individuals*
it lessens the certainty of the diagnosis. In tubercular peritonitis, the
aspirator or exploring needle will show more or less hæmorrhagic ad-
mixture in the effusion, a symptom not obtained in the simple variety.
Prognosis. The prognosis is unfavorable in the degree in which
it is unfavorable in other tubercular diseases, largely depending upon
the extent of the constitutional dyscrasia and upon existing complica-
tions. Bauer regards the prognosis as "absolutely fatal."
Treatment. A nourishing diet of easily digested food, calculated
to sustain the strength of the patient as far as possible, is very impor-
tant. The patient should be much in the open air, and take such
gentle exercise as his condition will permit, which is usually confined
to carriage and boat riding. Altogether, such dietetic and hygienic
rules should be observed as have been found useful in the treatment
of other forms of tubercular disease.
Therapeutics.-Calcarea ostrearum is the most important remedy. It is
indicated in leucophlegmatic persons, especially in children who have a distended ab-
domen, and whose mesenteric glands are hard and swollen.
Calcarea phos. is indicated when the nutrition is especially defective. The
child is emaciated and constantly hungry; eating does not satisfy, but always produces
more or less distress in the stomach. Frequently the osseous system is characteristi-
cally affected. There is a tardy closing of the fontanelles; the skull bones are soft and
thin, there is a great muscular weakness, with inability to walk or hold the head up,
and curvature of the spine.
Silicea. Especially useful in imperfectly nourished children with large abdo-
men, weak ankles, and profuse sweat about the head, the rest of the body being dry.
The fontanelles remain open; the head is large, and the body emaciated; the abdomen
swollen and hot. The child is very weak, and always cold. Diarrhoea is usually
present, the stools being very offensive.
Sulphur.—In scrofulous children, and especially when resulting from a suppressed
eruption. There is extreme emaciation, and great weakness, with deficient reactive
power.
Phosphorus.-When there is complication with pulmonary tuberculosis.
There is considerable tympanitis, with sensation of weakness and emptiness in the ab-
domen; painless debilitating diarrhoea of undigested food, and hectic fever.
Also consult Arsenic, Calcarea iod., Carbo veg., Iodine.
* Aran, De la Perit. chron. simple et tuberc, etc., L'Union Méd., 93, 1858.
DISEASES OF THE ORGANS OF DIGESTION.
845
CARCINOMA OF THE PERITONEUM.
BY J. G. GILCHRIST, M.D.
Carcinoma of the peritoneum is probably of as frequent occurrence as
cancer of other tissues or parts, but various circumstances naturally
combine to render an early diagnosis very difficult, if not practically
impossible. In late stages of the disease neighboring and contiguous
parts become implicated, and it is impossible to determine in which
tissue the disease had its origin. Owing to facts such as these, it was
long a matter of doubt whether cancer ever originates in the perito-
neum, and many were disposed to attribute all cases in which this
tissue was found affected to an extension of the morbid action from
some associated viscera. Later investigations, particularly by John.
Syer Bristowe, M.D., from the records of St. Thomas's Hospital, Lon-
don, would seem to settle the question in favor of the peritoneal origin
of cancer. The number of cases of carcinoma of the abdominal vis-
cera, particularly the primary forms of the disease, is not large, and
a comparatively small proportion of these cases showed evidences of
peritoneal origin. Assuming, as my theory of ætiology of carcinoma
does, that inflammation, or rather a modification of that process, is
the more frequent, if not the only cause of cancer, it would follow
that a tissue or organ is liable to cancerous disease in proportion to its
vascularity. This would certainly tend to prove, if proof were needed,
that the peritoneum may be the seat of primary carcinoma.
It goes without saying that even in cases of unquestioned primary
cancer of the peritoneum it is only a question of time when related
parts partake in the morbid action. There are few, if any, morbid
processes of which the peritoneum is the seat that do not extend with
great rapidity, owing to its peculiarly favorable anatomy, and carci-
noma is no exception to the rule. As is true of cancer elsewhere, it
rarely occurs in the peritoneum in young people, being to a consider-
able extent a disease of middle or advanced life. There does not seem
any predisposition of one sex over the other, but the natural history
of the disease in general would go to show that women should present
the greater number of cases. Of 22 cases cited by Bristowe (Reynolds's
System of Medicine, iii., p. 323), none occurred under twenty years of
age: "three occurred between twenty and thirty, four between thirty
and forty, five between forty and fifty, five between fifty and sixty,
five between sixty and seventy." Thus fifteen, approaching two-thirds
of the whole number (22), occurred after forty years of age, showing
the usual history of cancer in this respect. As to sex, no quotations
are made bearing on that point.
As to the varieties or forms of cancer developed in the peritoneum,
all four seem to occur with about the same frequency as in other tis-
846
A SYSTEM OF MEDICINE.
sues. Thus the order of frequency may be stated as scirrhus, enceph-
aloid, colloid, and melanosis, the latter either alone or as a complica-
tion of encephaloid. The first two, scirrhus and encephaloid, as is
usual, are more frequently primary, the latter oftener appearing as a
recurrent or secondary affection.
Scirrhus commences as a rule in the formation of exceedingly firm
and hard spots, quite circular in outline, but of the "split pea" form,
very small in the subserous tissue. They rarely exceed a line, or at
most two, in diameter, and are, scattered irregularly through the sub-
stance of the part. Later they become aggravated, forming larger or
smaller patches, until considerable portions of the membrane are in-
volved. At first the peritoneum seems thicker, but the nodules which
the cancerous deposits have now become do not project much, if any,
on the face surfaces, extending largely into the subserous tissues, and
exhibit the general character of scirrhus elsewhere, viz., to contract.
and draw movable parts into its substance. This characteristic prop-
erty has the effect to convert naturally pendulous folds or duplicatures
of peritoneum into dense cord-like masses, often very strikingly illus-
trated in the omentum. Such processes as the meso-colon, the mesen-
tery, or the appendices epiploica, are thus formed into hard tumors
or narrow and extremely indurated bands. Notwithstanding this is
the usual character of scirrhus, viz., contraction, yet there are instances
when the deposit has been in a circumscribed territory, when a distinct
tumor has formed, with all the characters of scirrhus elsewhere. There
is the same tendency, also, to ulceration of scirrhus that is commonly
observed. Perhaps the tendency to contraction is nowhere more pro-
nounced, nor productive of such discomfort and danger. Thus tubular
organs, as intestines, blood vessels, or various ducts, are drawn into the
growing mass, and either completely occluded or constricted to a de-
gree that very seriously impairs their efficiency.
Encephaloid commences, as cancer generally does, in the substance of
the part, in the subserous tissue, usually very early, or even from the
commencement, assuming distinct tumor characters. Not having the
same disposition to contraction, the masses project beyond the surface.
of the peritoneum, forming either solitary tumors or masses of small
tumors, like bunches of grapes or currants. In place of the indurated
contraction of scirrhus we find the volume of the affected tissues
greatly increased. The tumors, being small, are often found aggregated
in patches of greater or lesser size, but when larger they are usually
solitary. They are much softer than scirrhus, and have been found
polypoid or pedunculated. The usual size rarely exceeds a walnut,
but cases have been observed where the size of a child's head has been
attained.
Melanosis, while sometimes appearing as a distinct tumor in other
tissues, has never, according to Bristowe (loc. cit.), been observed in the
DISEASES OF THE ORGANS OF DIGESTION.
847
peritoneum. It occurs with some frequency, however, as a complica-
tion of encephaloid.
66
Colloid cancer, according to Bristowe (loc. cit.), has many distinctive
characters, which he puts as follows: In its early stage the disease
appears for the most part in the form of groups of vesicles which
vary in fineness, and have a close prima facie resemblance to patches
of eczema or herpes, or (if the fibroid element be abundant), in the
form of slightly granular or delicately reticulated patches. Later on,
the vesicle-like bodies are often as large as a millet-seed or tare. The
patches often become more or less elevated above the level of the sur-
rounding surface, and spread sometimes in tortuous and anastomosing
lines as though taking the course of the lymphatic vessels, sometimes
by forming scattered, isolated, somewhat pedunculated growths. This
disease, like scirrhus and encephaloid, tends in various degrees both
to involve, and to diffuse itself over, the peritoneal surface." When
fully developed, the colloid disease presents no peculiar characters.
It has, perhaps, rather less disposition to form outgrowing tumors, the
development being largely interstitial, thickening the peritoneum with-
out much induration, forming nodular projections, here and there, and
when the disease extends to near parts preferring to implant itself in
muscular or serous tissue to glandular structures. There are cases,
particularly when the stomach is affected, in which the omentum pre-
sents the appearance of scirrhus, being contracted, thickened, and in-
durated.
The above abbreviated account of what is a pure disease, rare, at
least, as to early detection, has purposely ignored much of the general
pathology of carcinoma. It is manifestly impossible for a cancerous
disease affecting the peritoneum to long remain solely related to that
tissue. It is equally impossible that such a serious tissue-change can
occur in a part as sensitive to morbid influences as the peritoneum,
without the establishment of other abnormalities, having the effect to
greatly enhance the danger. Thus peritonitis, with lymphatic, serous,
or purulent effusions, or obstructions of intestines, blood vessels, or
the lymphatic duct, may each and all occur, and very seriously com-
plicate an already sufficiently grave case.
Semeiology. The symptoms of peritoneal carcinoma are natu-
rally divisible into three groups, viz., those of the formative stage, of
the mature stage, and the stage of decline or degeneration.
(a) The growing or formative stage of cancer furnishes symptoms of
extreme ambiguity, and which, it would seem, can only occasionally
be correctly interpreted. There are pains probably referable to the
peritoneum, but not recognizable as indicative of cancer. There may
also be various disturbances of digestion, of which the usual symp-
toms of the tongue and bowels will be observed. There is often diar-
rhoea, at first, but later the bowels become constipated, increasingly so
848
A SYSTEM OF MEDICINE.
if constriction occurs. From the implication of the liver, which it is
found is frequently implicated (more so than any other viscus, after
the intestines), there will be jaundice. In fact, there may be a long
array of symptoms, perhaps distinctly referable to certain organs, or
sets of organs, but there is rarely any clue to the actual cause. In
cases of secondary or recurrent cancer, after the removal or develop-
ment of a cancer on the surface of the body, or of the viscera, when
a diagnosis can be made the appearance of symptoms such as these
may be suggestive of invasion of the peritoneum; even then, unfor-
tunately, it is not possible to determine whether the disease originated
in the peritoneum, or extended to it from near parts.
(b) The mature stage will usually give symptoms which are pathog-
nomonic. It is very rarely that this stage is reached without there
being a degree of emaciation that will enable the physician to detect
something suggestive, at least, of the state of affairs. The abdomen
will often be somewhat full, and yet quite resisting to pressure. There
will be discovered more or less clearly defined tumors, but which may
easily be mistaken for enlarged mesenteric glands. The peculiarly
lancinating pain, the feeling of immobility of the tumors, will suggest
carcinoma. Even with such prominence in the indications of carci-
noma, there is little to enable the physican to determine whether it is
of the peritoneum or mesentery. So far as indications for treatment
are concerned, perhaps it makes little difference whether a diagnosis
is made or not.
(c) In the degenerative stage carcinoma is generally easily made out.
If other symptoms have been lacking hitherto, the establishment of
cachexia would set the matter at rest. When the omentum is the seat
of colloid or scirrhous disease, it can usually be felt as a hard ridge or
band running across the abdomen, and is really more diagnostic than
the tumors that may also exist.
Under all conditions, it must be conceded, and in all stages of the
disease, a diagnosis can rarely, if ever, be satisfactorily reached when
the disease is primary in the peritoneum. Even when secondary or
recurrent, it is at best a more or less well-founded suspicion.
Prognosis. As with carcinoma generally, a prognosis is almost.
invariably bad. If it is assumed that the disease is curable in the
early stages, the fact that it is rarely recognized until it has become.
developed forbids any hope of a cure. The prognosis is additionally
unfavorable, if such a thing be possible, when the disease occurs sec-
ondarily.
Treatment. As may be inferred from the above, little, if any,
hope of a cure can be held out. The records of homoeopathic prac-
tice do not give instances of a cure; in fact, so far as my reading
goes, I do not find the condition referred to at all. Considering it as
cancer in general, epithelioma and colloid might be considered some-
DISEASES OF THE ORGANS OF DIGESTION.
849
what amenable to treatment, either to arrest or retard development,
even if no hope of a cure exists. But these forms of cancer have been
cured when early recognized. The difficulty in the present instance
is an early recognition; without it, I do not believe a cure possible.
Based upon the records attainable, if the case is recognized, Sanguina-
ria, Crocus sat., Phosphorus, Arsenicum, or Hydrastis, might be used as
the general indications in the case would suggest. Should the case be
one of scirrhus, Carbo an., Lapis alb., Carbolic acid, Arsenicum, or Hydrastis
may be used, but I do not believe that the slightest beneficial effect
will result. The office of the physician, in these unfortunate cases, is
reduced to the simple function of affording relief from suffering by
any means at his command, a purely palliative function. Knowing,
as it would seem all must know, that the disease is practically incurable,
he will feel compelled to devote his energies to make the patient as
comfortable as may lie in his power.
ASCITES.
BY E. U. JONES, M.D.
From the Greek, Askites.
Synonyms.—Hydrops abdominis, Hydrops peritonei, Hydroperi-
toneum, Hydrops saccatum, Abdominal dropsy.
Situation.—Entirely within the peritoneal sac.
History. There is no time when this disease was not known. It
was early diagnosticated by the ancients, and separated by them from
general dropsy. The treatment, however, was the same, and the causes
were not separated from those considered as causing any collection of
water within the body.
Etiology. Ascites is nearly always symptomatic, so nearly so that
it may usually be considered as depending upon the presence of some
other preëxisting disease, and having a strict relation to the character
of that disease. Speaking generally, it will be found to depend upon
some form of obstruction of the circulatory system, by which serous
portions of the blood are allowed, or rather forced, to escape into the
peritoneal cavity. This obstruction exists most commonly in the capil-
laries alone, but a similar state of the larger vessels may also exist,
though producing other symptoms to indicate its presence. It may be
general or sacculated, existing either in the open abdominal cavity, or
in that cavity divided by adhesions into several sacs. Encysted ab-
dominal dropsy is not, properly speaking, ascites, and is not usually
amenable to the ordinary treatment of ascites. There is a possible.
primary peritoneal dropsy depending upon cold, affecting either the
orifices of the lymphatic ducts, or increasing the functional activity of
the epithelial cells, but secondary causes, arising from diseases of the
VOL. I.-54
850
A SYSTEM OF MEDICINE.
organs situated within the abdominal walls, are by far the most
common. The most general action of these secondary causes is by
constriction, pressure, or other modes of obstruction of the circulation
through the several organs, by means of aneurisms, tumors external to
the organs themselves, inflammation of the peritoneum or any portion
thereof, or by degenerative action within, or connected with, the
organs. Sometimes there is an extension of disease from one organ,
in which the disease would not tend to produce ascites, to another
organ, resulting in an obstinate and incurable dropsy. This dropsy
may be accompanied in the last stages of its causative disease by œdema
pedum, or even by general anasarca, but in every instance of true
ascites these extensions of the effusion are caused by the pressure of
the original ascites upon the larger vessels of the trunk, preventing the
return of the blood from the extremities. The removal of the ascites
is their cure, and, so far as this study is concerned, they will not be
considered.
An intimate causative connection exists between ascites and obstruc-
tion of the portal circulation; hence, one of its common causes will be
found in some form of hepatic disease.
Adhesive inflammation of the liver is one of the most frequent of
these diseases, especially as it presents itself as cirrhosis. Ascites is a
sure accompaniment, commencing after the atrophy succeeding the
enlargement is fully established, and therefore being one of the last
symptoms of the causative disease. If the diagnosis of that disease
has been satisfactorily made previous to the presence of the ascites, the
coming of the effusion may be assured and in a measure guarded
against. The premonitory symptoms of any of the diseases ending in
atrophy of the liver, whether such atrophy may be due to compression
from without, to confirmed alcoholism, to constitutional syphilis, or to
pressure from within, are but seldom referred to the true cause, are
slight, and but little notice is taken of them at the first. They are
more usually considered as a form of dyspepsia, with a loss of true
appetite, furred tongue, languor, a dull pain in the right hypochondre,
with commonly but little disturbance of the bowels,-in fact, the usual
train of the so-called "biliousness." Close examination will detect a
slight enlargement of the liver, but the patient is not ordinarily pre-
vented from his usual occupation, and a few domestic remedies, or a
little patent" medicine," satisfy him. Too often he knows that hist
habits are such as will condemn him, and he thinks the trouble will
soon pass away. It is impossible to assign the length of this prodromal
stage of the ascites, as it may have been coming on for months, or even
years. The deposition of lymph is very slow, the fibrinous contraction
still slower, and it is not unfrequent that attention is not called to the
trouble until ascites has shown itself. The difficulty of finding the
usual hepatic dulness on percussion, and the rough, dry skin, may call
DISEASES OF THE ORGANS OF DIGESTION.
851
the attention of the physician to the real condition. In hospital prac-
tice this stage may be more accurately noted; in private practice less
so. The acute form of effusive hepatitis, however, demands treatment,
and the attention of the physician is at once called to the disease by
the fever, tenderness on pressure, the jaundiced hue, and the highly
colored urine. The supervention of ascites upon this form is almost
wholly under control, but the patient should never be left for "nature
to complete the cure." True cirrhosis of the liver is seldom seen under
thirty years of age, and one of its common accompaniments is hæm-
atemesis, the occurrence of which, the other symptomatic indications.
agreeing, may be taken as a diagnostic symptom of this disease. The
pathological cause is the contraction or the complete obliteration of
the smaller branches of the portal vein, preventing the full circulation.
of the blood in the liver.
The more common cause of cirrhosis, and therefore of ascites, is
alcohol. The trouble is not usually found with those who drink the
lighter liquors, but with chronic, reckless drinkers, who take all their
liquors without diluting them, giving the alcohol free action. In this
class of patients the diagnosis will be easy, the prognosis plain, and the
predetermining disease undoubted. In many of these cases syphilis
is a complication and, when present, cannot be ignored, and in the
palliative treatment must be taken account of.
Cancer of the liver also produces ascites. This it does by mechanical
and uneven pressure upon the capillaries of the portal vein, generally
obstructing its circulation to a less degree than in cirrhosis, the ascites
consequently being less severe. The objective symptoms are very
nearly the same, and it is often difficult to distinguish the cancerous
complexion from that sallow hue accompanying yellow atrophy.
Symptomatic differences are: a moist, rather than a dry, skin; often
sweating, with hectic; an enlargement, often irregular, of the liver in-
stead of atrophy; may occur at any age; and is not necessarily con-
nected with alcoholism.
Cancer of the omentum is also a cause of ascites, though very rare,
and will require an unusually careful diagnosis. It may be prob-
abilized by the degree of fever, the absence of direct hepatic disease,
the greater and more rapid emaciation, the moist skin, and the more
diffused pain.
Chronic enlargement of the spleen probably sometimes causes as-
cites, but it is a question whether it does so from mechanical pres-
sure merely or from some accompanying disease of the liver. The
organ may be easily detected in the left hypochondrium; the skin
is moist; and the ascites frequently disappears, apparently of its own
will. This cause may most commonly be found in malarial regions.
Chronic inflammation of the peritoneum frequently results in ascites,
and among the temperate classes is, perhaps, the most common cause.
852
A SYSTEM OF MEDICINE.
Its own exciting causes may be very many,-chill, in all of the various
forms which so frequently give rise to inflammations of other mem-
branes; tubercular deposit; injuries of the abdomen; metastatic causes;
sequelae or accompaniments of other fevers, as the exanthemata, inter-
mittents, erysipelatic, rheumatic; and, perhaps, a depraved condition.
of the blood, arising from faulty secretion or innutrition, and then de-
veloped by some slight local cause. Its diagnosis is comparatively
easy. There is a certain amount of hectic fever, with general abdom-
inal tenderness, varying in degree, however; the effusion is not so great
as in the hepatic causes, and, except when the ascites becomes immense,
is not accompanied by any anasarca; the emaciation is slow; the skin
is not harsh, and its color is not changed; and absorption of the fluid
frequently takes place spontaneously.
Diagnosis.-Ascites is the presence within the abdominal cavity,
and properly nowhere else, of a peculiar serous fluid, usually light
yellow in color,-though sometimes, in cirrhosis, of a brown hue from
the presence of blood or bile-pigment-rich in albumen and commonly
containing fibrinogen. It is not an idiopathic disease, but always
symptomatic, and is classed as a disease only as it becomes the most
persistent, annoying and visible evidence of disease, the sufferer from
which demands its removal. Different from anasarca, its fluid is con-
fined within a limited and specific region, its causes being as limited
and specific. When the preëxisting disease has been slow and in-
sidious, the attention is first called to a certain embonpoint, without a
corresponding apparent increase of flesh in other portions of the body.
There is a dyspnoea, accompanied by easily increased rapidity of the
pulse, and the patient becomes sensible that he has a heart, and sup-
poses that he has some disease thereof. In the cases of drunkards
this conclusion is quickly and naturally reached. The urine may not
be sensibly reduced in quantity at first, though it is usually high
colored. In cases of hepatic disease the complexion becomes sallow,
and the skin dry and rough, but in ascites from other causes there may
be no apparent change in the complexion, and the skin may be moist
and even easily sweating. Dyspeptic symptoms are almost universally
complained of, and in some cases there have been found on autopsy
organic changes in the gastric membranes. The appearance of the ab-
domen differs with the position of the body. If the distension is not
very great, and the position is upright, its lower portion will be the
more dependent, and the upper portion drawn downward. By placing
the patient upon the back, the abdomen flattens at the umbilicus, but
increases at the sides, and the dyspnoea increases. In any position,
fluctuation may be detected by placing the hand lightly upon one side
of the abdomen and percussing with the fingers of the other hand. In
cases in which the effusion is small, this fluctuation can be perceived
by bringing the hands very near together, and percussing very lightly,
DISEASES OF THE ORGANS OF DIGESTION.
853
but it is best always to supplement this examination with other marked
symptoms before a sure diagnosis is given. An examination of the
urine may not show any difference peculiar to the ascitic situation,
but it may be more scanty than usual and higher colored, with a
higher specific gravity. In true ascites there is seldom any effusion
apparent in other parts of the body, but in its advanced stages it may,
by its own pressure, retard the return of the blood from the extremi-
ties, and thus produce oedema of the feet. Ascites may be a part of
general anasarca; its diagnosis has then been made before its appear-
ance.
Differential Diagnosis.-There are but few pathological states
with which ascites could well be confounded. One of these is encysted
effusions, either unilocular or multilocular, especially when the result
of ovarian disease. This form is not generally amenable to the treat-
ment of ordinary dropsies, and has no direct relation to ascites. If the
woman be placed upon her back, the abdomen will preserve its pro-
tuberance, not flattening out as in ascites; percussion will continue its
dull sound over the same regions as in the erect posture, while in as-
cites the floating of the bowels to the upper portion of the abdomen,
in whatever position the patient may be placed, will cause a change in
the location of the resonance; ascites is uniform in its enlargement of
the abdomen, except when confined by adhesive inflammation, while
ovarian dropsy is more unilateral in its manifestation. The history
of the case will often decide the diagnosis, especially if a preëxisting
peritonitis be established, and the presence or absence of the habit of
spirit-drinking. There are cases of enormous distension of the bladder
which may simulate ascites, but, if there be any doubt upon the point,
the introduction of the catheter will decide it. It would seem almost
impossible that the gravid uterus should be mistaken for ascites, but
the mistake has been made many times. The history of the case
should always be carefully had, and the probabilities estimated. The
general health of the woman; the absence of the menses, except in
those abnormal cases in which they continue during the whole preg-
nancy; the absence of fluctuation; the movement of the womb on
ballottement; and the dulness on percussion in all positions, will make
the diagnosis positive. There are certain cases of chronic tympanitis
which possibly may be thought to be ascites, a condition more com-
monly to be found among those whose diet is not of the best and is
largely vegetable. The resonance on percussion is, however, very
strongly marked, and it is with difficulty that dulness can be found
anywhere in the abdomen. This will be the diagnostic point, for the
accompanying gastric difficulties are also found in diseases of the liver.
It is possible that tubercular peritonitis may simulate ascites, but the
tenderness on pressure, sometimes scarcely bearing the necessary ex-
amination, the discovery of the enlarged and lobed omentum, the
854
A SYSTEM OF MEDICINE.
absence of marked fluctuation, and the tuberculous dyscrasia, will aid
the decision.
Prognosis. In the majority of cases the prognosis is doubtful, for
these cases occur among the poorer classes and among those least well
nourished. It is with these that organic changes of the liver are the
most frequent, and the ascites is but the evidence of their existence
and of the hopelessness of their recovery. In cirrhosis of the liver,
after the deposition of lymph in the course of the ramification of the
portal vein, and when the organized exudate has exerted its contractile
power, there is no possible hope of recovery. The ascites remains per-
sistent, and powerfully aids in shortening life. The same is true of the
changes caused by all malignant hepatic growths. In the ascites.
charged to diseases of the spleen, there being no organic diseases of the
liver preexisting, and in that caused by peritoneal inflammation, the
prognosis is better. Spontaneous absorption of the effusion which was
in supposed connection with each of these causes has occurred, and
they are both amenable to medicine. After the inflammatory condi-
tion on which the ascites had depended has been cured, or has ceased
to continue in active process, the effusion may remain, and seems easily
controllable by the appropriate remedy.
Treatment. From the etiology it will be seen that all cases of
ascites are not amenable to curative treatment; much may be done,
however, to palliate and to retard the fatal issue. It will be well to
determine the remediability or the irremediability of a case as early
in its progress as possible, and not to waste time in fruitless endeavors.
The medicinal treatment for relief should not be directed to the re-
moval of the dropsy alone, but rather to the whole condition of the
patient, increasing his powers of resistance, seeking to enable the as-
similation of food,-thereby checking the progressive emaciation, and
giving a new vitality to the effluent nervous forces. It is not with
every one of these cases that the same diet can be given, but it will
oftenest be found that the more concentrated forms of animal food,
with the diluent water, coffee, etc., given at a time other than when the
food is taken, will be well borne for one or two of the daily meals, the
others, for a while, being composed of the cereals, varied in their se-
lection, with milk or malt. In very many of these cases the dyspeptic
symptoms are those most complained of, and even their partial relief
takes away something from the misery of living. Markedly is this the
case before hæmorrhages have begun, and while a certain portion of
moral activity still remains. For in many of the cases having their
remote causes in alcoholism, the anæmic brain can but slowly respond
to mental or moral stimulus, and a dreary hopelessness affords but
little ground for work.
The remedies to be selected for this purpose are those which affect
profoundly the organic nervous system, each in their several methods.
DISEASES OF THE ORGANS OF DIGESTION.
855
Arsenicum.-But few autopsies of chronic arsenical poisoning, sufficiently
chronic to have developed all of the organic changes of which this medicament is ca-
pable, have been had; nor has diffuse interstitial hepatitis been found among its conse-
quents Yet it cannot be doubted that it is a remedy of much power over the func-
tions of the liver. In primary acute inflammation of this organ, with feeling of fulness
and burning pain, venous engorgement tending to hæmorrhage, utter prostration, and
restlessness, melænic vomiting or stools; or in secondary inflammation during other
organic changes, with the same marked symptoms, Arsenic is potent. In the dyspep-
sia caused by the sub-acute gastritis of drunkards, with burning pain, tenderness over
the region of the stomach, constant thirst, which cold water allays the best of anything
for the time, but which cannot be retained long, with pale face and functional starva-
tion, this remedy is needed. When there is a sense of constant pressure and weight,
unrelieved by eating, sallow complexion, gnawing, corroding pains, with a history in-
dicating a cancerous diathesis; or when, with a like history, there are sharp lancinating
pains in the right hypochondre, hardness of the liver to the touch, obstinate constipa-
tion, or yellowish, greenish, or black diarrhoea, Arsenic may be given with good effect.
Hydrastis can.-The sphere of Hydrastis covers that of the whole nutritive
system, and primarily governs the mucous surfaces. It has considerable reputation in
general cancerous affections, and, while by no means a specific, has afforded great re-
lief in many of this class of diseases. In debility from the loss of animal fluids (like
china), in empty abdominal feeling, as if the abdomen were hollowed (and it may be
actually so), in the "goneness" of the stomach without relief from eating, hydrastis
indicates its sphere. There is some reason to suppose that it will cause enlarge-
ment of the liver, becoming chronic; and intestinal hemorrhages by no means contra-
indicate it.
Hydrocotyle asiatica.-"Cirrhosis of the liver, hypertrophy and indura-
tion of connective tissues obstruction in the whole hepatic region; slight pain in the
upper portion of the liver; crampy pains in the stomach without nausea." I have had
no experience in these diseases with this remedy, but its symptomatic indications are
a perfect analogue of chronic alcoholism.
Lachesis. In these affections Lachesis ranks with Hydrastis and Lycopodium,
and in the failure of either of these remedies may be expected to work well. Its
organic action, perhaps through the cerebro-spinal nervous system, is deep and per-
sistent. It is more indicated in that anomalons class of cases which ignore nosolog-
ical arrangement, and as an intercurrent with other remedies. Muscular tremors,
cardiac weakness, nervous asthma, grayish complexion and extreme irritability, and
left-sidedness, are general conditions for which it may be chosen.
Lycopodium.-A strict impression of the ganglionic nervous system, spending
its force principally upon the liver and the digestive tract. The patient is usually
cachectic; muscles loose and flabby; and suffers from chronicity in all his ailments.
He is commonly hypochondriacal; blustering perhaps, but timid; chronic hepatitis,
with the region very sensitive to the touch or to motion; feeling of tension, as from
a hoop around the hypochondria; excessive flatulence, as if in the left trans-
verse colon; lithic acid diathesis, with red sand in the urine. Of great value in true
ascites.
Nitric acid is a remedy not to be forgotten in this disease, to be changed some-
times for the combination Nitro-hydrochloric, especially for those who have been
under mercurial treatment or have suffered from syphilis. Excessive emacia-
tion, particularly of the upper arms and thighs, with enlargement and torpor of the
liver; stitching pains in the liver; jaundice with clay-colored stools; frequent epis-
taxis; pressure and burning pain in the stomach as if he would vomit blood; glandular
swellings.
Nux vomica.-A decided cerebro-spinal irritant. When ascites has alcoholism
for its primary cause there is no remedy which will be more often called for than
this; and when hepatic enlargement and induration have occurred from long-continued
"high living" it cannot be omitted. Excessive sensitiveness of the peripheral
nerves; attacks of tetanic rigidity; constipation; thirst; vertigo; loss of appetite, and
cadaveric appearance demand it.
Phosphorus.-The great reconstructor of weakened nerve force. It has a spe-
cific and profound influence upon the liver and intestinal tract, though there is no
organ in the body which does not feel its influence. Pathologically it produces fatty
degeneration of the liver, diffuse interstitial inflammation, and "genuine alcohol cir-
rhosis." The atrophy succeeds the previous hypertrophy; the jaundice is dark, ma-
lignant; the urine scanty, albuminous. The stomach has oppression and burning,
856
A SYSTEM OF MEDICINE.
with great thirst and extreme sensitiveness; vomiting soon after drinking, or vomiting
of blood, or of coffee-colored masses. Stool dry and scanty, or persistent diarrhoea.
Rapid emaciation.
Other remedies are: Aurum, Bryonia, China, Iodine, Mercurius,
Ptelea trifoliata, Sulphur.
The curable forms of ascites are those arising from certain diseases
of the spleen and peritoneum. These forms are not necessarily fatal,
and when not so, are limited in their progress and tend to retrogression.
Hence the ascitic effusion is sometimes spontaneously absorbed, and
a complete cure results. But it is still a mooted question whether in-
flammation of these organs ever produces dropsy per se, or whether
collateral inflammatory disease of some other organ does not produce
stasis in the abdominal vessels, and thereby gives rise to the effusion.
This the more as ascites is by no means a necessary adjunct of either
of these inflammations, and is often absent in severe and chronic cases.
Be this as it may, we have to deal here with the fact of the effusion
and its remedies, leaving a wider discussion of its mode of causation
to the papers upon the diseases of those organs.
The spleen shows its greatest susceptibility to disease in the middle.
adult age, and then manifests its close connection with diseases of the
stomach and liver. The same causes which result in enlargement of
the liver may also produce inflammation and enlargement of the spleen,
perhaps through the connection of the splenic vein with the portal
vein. A similar condition of the mesenteric glands is by no means an
unusual complication. Splenic anemia is common, and, secondarily
affecting other organs, may conduce to the formation of ascites. The
weakened blood vessels easily allow their contents to escape, hence the
violent epistaxis so common in chronic splenic inflammations. Ma-
larial conditions, particularly if they have become chronic; badly
treated intermittents; typhoid fevers; puerperal fever; chronic peri-
tonitis; and diseases affecting the portal circulation, are causes of those
engorgements of the spleen which may result in ascites. To these
may be added infectious diseases and syphilis.
In connection with diseases of the peritoneum ascites is not uncom-
mon. The amount effused may be so small that it cannot be ascer-
tained by palpation, or it may be so great as to cause, by its own
pressure upon the abdominal vessels, a general anasarca. Whether
ascites is ever engendered idiopathically from the peritoneal mem-
brane is an open question, but many cases of this disease seem to
admit of no other solution. Acute idiopathic peritonitis itself is de-
nied, but deemed secondary to diseases of those organs invested by it.
Or it may be excited by cold, rheumatic or general morbific causes;
chronic forms of renal troubles; diseases of the female sexual organs;
pregnancy, in all of which it may seem to be idiopathic. It may be
secondary to any disease of the stomach or intestines by which they
DISEASES OF THE ORGANS OF DIGESTION.
857
are occluded, or by which stasis is caused in their blood vessels; to
ulcerations, with or without perforation, as in typhoid fever or dysen-
tery; to typhlitis; to various abdominal glandular inflammations; and
to different forms of abdominal phlebitis. The chronic form may be
due to many
of the causes which induce the acute, but may also follow
an acute peritonitis, or may be the sequel of peritoneal or mesenteric
tuberculosis, or be traumatic. (For diagnosis of these various causes
see, among others, article on Diseases of the Peritoneum.")
In the beginning of ascites from primary or secondary inflammation
of the peritoneum, the urine, at first, may be normal in amount, or
but little lessened. It soon, however, becomes scanty and high-colored,
with a copious deposit of urates. This may be due to various causes,
as the fact of the effusion itself, low arterial pressure, and, later, the
pressure exerted upon the renal arteries.
Treatment. The indications are to cure, if possible, the morbid
conditions on which the ascites depends, and to promote the absorp-
tion and elimination of the fluid by the kidneys and the skin, or, in
some cases, by the bowels. Hence the remedy must always be one
having a specific relation to the cause, to be followed, or alternated,
with one of the following:
Apis mel.*—All of its pains are stinging-burning; palpitation of the heart, as
if one had been running; ædema of the eyelids; urine scanty, dark colored; great
soreness of abdominal walls. It produces dropsical inflammations of all serous mem-
branes.
Apocynum cann.-Acting less forcibly on the serous membranes, and more
so upon the glandular system. Stomach exceedingly irritable, rejecting everything;
ascites with bruised sensation of the abdomen; sinking feeling at stomach; urine ex-
cessively scanty, thick, yellow and turbid; looseness of the skin of the eyelids. "When-
ever it acts beneficially, the skin becomes moist before the secretion of urine becomes
abundant."
Arsenicum.-Pale, earthy or sallow countenance; great debility, with faintness
on the slightest motion; great thirst, but drinks but little; sensation of burning heat
all through the body, while the skin is cool; all pains burning; urine scanty, high-
colored.
China.-Splenic ascites, and from functional disturbance of the liver; anæmia.
In ascites in malarial regions it, or its alkaloid, may become absolutely necessary.
Lycopodium.-When as a cause, or in connection with the cause, of ascites
there has been large indulgence in alcoholic drinks; urine scanty, with deposition of
urates; emaciation of the upper body; one foot cold, the other hot; the pain is in-
creased by incarcerated flatulence.
Other remedies: Aurum, Bryonia, Fluoric acid, Helleborus, Lep-
tandra, Senecio, Copaiva, Elaterium.
Adjuvants.-Compression.-Great assistance in the resorption has
often been found in the judicious use of compression, compelling
moisture of the skin and increased action of the mucous membranes.
A remarkable illustration of its value is reported in the North American
This remedy is often unreliable, seeming to deteriorate. I have found success
with fresh preparations.
858
A SYSTEM OF MEDICINE.
Journal of Homœopathy, vol. xvi., p. 523, by B. F. Cornell, M.D. It had
been of six years' duration, and arose from repercussion of rubeola.
The whole body was enlarged; there was no waist, the expansion
commencing at the clavicle in front, and the axilla on the sides; the
back was broad, the false ribs and the lower portion of the sternum
were much distended, making the distension uniform from the throat
to the lower portion of the bowels. Her general health was not very
materially impaired. Paracentesis was decided upon. "I prepared a
bandage about three inches wide and many yards in length ; the tro-
car was introduced in the linea alba, and as the fluid escaped I com-
menced applying the bandage around the body, commencing at the
axilla with as much tension as she could bear; this prevented faint-
ness or exhaustion. The fluid was fifty-five minutes in discharging,
measured 12 gallons, and weighed 100 pounds and 12 ounces. The
day before the operation she weighed 202 pounds, the day after, 98
pounds. The fluid was of a straw color; she sat up during the entire
discharge. After she had rested some four hours I removed the band-
age, and the following condition was presented. The integuments at
the navel could be carried around like a blanket 5 inches beyond the
spine. The ribs spread outward, and the diaphragm was so much
distended that a large loaf of bread could be passed up under the
ribs on either side to above the false ribs. I had a corset prepared,
and, after bathing the body with dilute alcohol, and rubbing it vigor-
ously with the hand for several minutes, the corset was put on, and
laced with as much force as could be endured; then applied the band-
age as before. I had these removed every day, and, after bathing and
friction with the hand, applied again. I pursued this course for some
thirty days, when I left it off at night; some two weeks after, aban-
doned it entirely, substituting one broad bandage pinned tightly
around the abdomen. The corset was continued till the ribs com-
pressed into the natural form; the integuments gradually contracted,
and in the course of a year the shape had become nearly natural.
The only remedies used internally were diuretics, tincture of iron, and
an alkali made by burning grape-vine, the ashes put into water, and
taken after eating. No accumulation of fluid followed the operation.
I attribute the cure to compression."
Paracentesis.-This operation may be necessary in advanced
stages of the disease, especially in hopeless cases or while awaiting
the action of the appropriate remedies; but it is at best only pallia-
tive. Cases are on record in which there seemed to be no return of
the dropsy after the operation, but in every instance some medicines
were exhibited which appeared best suited to the general condition of
the patient. These medicines must have played a part in the cure,
though it is not impossible that a dropsy once established may per-
petuate itself, after the removal of the primary cause, by the pressure
DISEASES OF THE ORGANS OF DIGESTION.
859
it exerts on the renal vessels. For the mode of operation consult the
works on surgery.
Hot water is a grand aid in relieving the pains which sometimes
accompany ascites.
It is best applied over the whole abdomen,
through many thicknesses of cloth covered with an overlapping flannel
bandage.
Position has much to do with the relief of these cases. When the
effusion is large, and the diaphragm pressed strongly upward, the
heart and lungs are obliged to fulfil their duties in a lessened space,
and, in consequence, dyspnoea and faintness are not unusual symp-
toms. Rest in the usual position of health is impossible, but the head
and shoulders must be placed high, and the patient be posed partly
upon his right side.
F. DISEASES OF THE LIVER.
BY W. H. DICKINSON, M.D.
CONGESTION OF THE LIVER.
Definition. Congestion of the liver denotes a condition of that
organ in which there is found an abnormal accumulation of blood in
its substance, with the consequent symmetrical enlargement which
this hyperæmia necessarily implies. Whether this congestion shall
presently subside with the passing away of the cause which gave rise
to it, and so be classed as acute, or become chronic, is a matter deter-
mined by the circumstances or habits of the individual. There is no
essential difference of character between acute and chronic congestion;
it is merely a question of duration.
Etiology. The causes lying back of this affection differ widely,
and may be divided into two general classes. First, we have the me-
chanical causes. Anything which retards the egress of blood from
the liver must, of necessity, tend to pile it up in the meshes of this
great sponge. What condition implies this retardation? Embarrass-
ment of the thoracic circulation. So it comes about that valvular
disorder of the heart, such as mitral insufficiency, by making the
transit of the blood through the chest difficult, becomes responsible for
congestion of the liver. Even diseases of the respiratory apparatus
which impede the passage of blood through the lungs, or compression
of the vena cava by tumors, may have the same undesirable effect
upon the hepatic circulation. Given any condition which makes the
return of the blood from the liver to the heart slow and laborious, we
are justified in looking for congestion of the liver as a result. These
congestions are purely mechanical, are known as passive congestion,
are due to morbid conditions existing elsewhere, and their removal
*
860
A SYSTEM OF MEDICINE.
being dependent upon remedial measures addressed to other organs,
no further notice will be taken of them in this connection.
Those causes which make up the list of the second series, are imme-
diately concerned with the functional life of the gland. Prominent
among them is that peculiar cachexia induced by malarial poisoning,
so familiar to every physician. Another cause is found in excesses of
the table. Overeating, especially of rich and stimulating foods, and
the use of liquor of any sort, are powerful agents for the production
of a congested state of the liver. Nor need we wonder that such is
the case, for when it is remembered that, by means of its portal vein,
the liver runs away with the greater part of a man's dinner, the first
of all tissues and organs, save only the stomach, to make its requisi-
tion and do its work, it is not surprising that it should early feel those.
influences which make for abdominal plethora. In tropical climates,
active exertion is often followed by a congestion of the liver which is
marked by a hypersecretion of bile and an intestinal disturbance
taking the form of dysentery. Such attacks may be very acute, while
the more chronic class of tropical congestions seem to result from the
mere influence of prolonged residence. Finally, an overloaded liver
may accompany uterine ill-health, and, also, according to Jousset,
leucocythemia. These causes of the second class are followed by
active congestions, in contradistinction to the passive congestions which
result from the obstructions of the circulation. In recognition of this
difference, some authorities specify two varieties of the disorder in
hand, the active and the passive.
Pathology. At the post-mortem examination, the swelling of the
liver is found to be proportionate to the degree of congestion existing;
the increase in the size of the organ is more marked in its thickness
than in its length. If the swelling is great, the coats of the liver assume
a smooth, shining appearance.
In recent cases blood flows freely on section, but later the blood is
thicker, and the cut surfaces appear dark or spotted. According to
Niemyer, this is particularly apt to occur when there has been con-
gestion for a long time; dark spots, corresponding to the dilated venæ
centrales, the commencement of the hepatic veins, and varying in shape
with the direction of the cut, alternate with brighter colored spots which
do not contain so much blood, and which represent the termination of
the portal vessels. The spotted appearance which has given rise to the
much misused name of nutmeg liver becomes still more marked when
the more bloodless spots in the vicinity of the dilated central veins
appear decidedly yellow from obstruction of the bile-ducts. The latter
may be partly due to catarrh of the gall-ducts, induced by the hyper-
æmia of their mucous membrane, partly to the pressure of the en-
larged vessels obstructing the free escape of bile from the small bile-
* Niemeyer's Practical Medicine, vol. i., page 659.
DISEASES OF THE ORGANS OF DIGESTION.
861
ducts; and to gastro-duodenal catarrh, induced by the same causes
which excite the hyperemia of the liver.
After the hyperæmia has existed for a length of time, a slow atrophic
degeneration of the organ takes place, the pathology of which is not
altogether established. Bartholow* says this condition consists in a
wasting and disappearance of those cells lying in contact with the
dilated central vein, their places being supplied by connective tissue
having a granular appearance. The disappearance of these cells and
the contraction of the newly-formed connective tissue cause a diminu-
tion in the size of the liver, and an increase of its density, so that this
state is often confounded with cirrhosis; but the substance of the organ
has not the density, nor are there present the prominences which give
the nodular aspect to the latter. These conditions are usually present
when the congestion results from obstruction in the heart or lungs, this
being the most frequent cause of hepatic congestion. Frerichs† ex-
plains the modus operandi by which these changes are wrought by
saying that when valvular diseases of the heart are present, especially
constriction of the left auriculo-ventricular opening, incompetence of
the mitral, and still more of the bicuspid valves, and further in affec-
tions of the lungs, which greatly impede the circulation through the
pulmonary artery, as in emphysema, the liver becomes a powerful
agency in the circulation of the blood. "The suction power exercised
during inspiration is either more or less powerful than it ought to be;
either the blood in the vena cava and hepatic veins is subjected to a
higher degree of pressure, which interferes with the evacuation of the
capillaries of the portal vein, or the current of blood regurgitates with
each systole of the heart into the hepatic veins. When this is the case,
the branches of the hepatic vein in the liver continue permanently dis-
tended, and gradually enlarge, while their walls become hypertrophied;
the stagnation is propagated to the portal vein and to the organs in
which this vessel takes its origin, and there results a series of derange-
ments in the functions and nutrition of the liver, and of the organs
comprised in the portal system." Thus we obtain the pathological
changes in the liver, as before described, and may also find the vessels
of the mucous membrane of the stomach and intestine, of the spleen,
pancreas, etc., distended with venous blood, sometimes giving rise to a
deposit of black pigment, and sometimes to erosions and ulcerations.
The spleen, at first increased in volume, is usually found normal in
size, but solid and firm. There is generally found an excessive mucous
and serous effusion, the latter having given rise to ascites with or with-
out anasarca. Sometimes, old extravasations of blood are found be-
tween the folds of the mesentery, the mesenteric glands being of a
* Bartholow's Practice of Medicine, page 142.
† A Clinical Treatise on Diseases of the Liver, Wm. Wood & Co., New York, 1879,
vol. ii., page 35.
862
A SYSTEM OF MEDICINE.
livid tinge, with congestive swelling and serous infiltration of the pan-
creas.
Where the congestion has resulted from long-continued excesses in
diet, or from the use of alcoholic liquors, or from malarial poisoning,
we may obtain various modifications of the changes before described.
Often, under such circumstances, the congestion is more intense in its
character and, while not resulting in the peculiar character of changes
as we have described, may induce serious structural lesions, hæmor-
rhages, softening of the parenchyma, abscesses, hypertrophia, fatty de-
generation, or induration, and occasionally cirrhotic degeneration with
atrophy.
Symptomatology.-The local symptoms of congestion of the liver
are uniform enlargement of the gland, with the consequent increase in
the area of dulness as defined by percussion, and sensations of weight,
fulness and constriction in the right hypochondriac region, with a dull,
annoying pain which reaches out posteriorly to a point beneath the
shoulder-blade of the same side, and is aggravated when the patient.
is lying down, by change of position from the right side, on which he
instinctively lies, to the left.
The general symptoms show themselves in a complexion which be-
comes muddy or dusky, in the yellowish tinge of the conjunctiva, in
the constipation with stools which are "off color" (in rare cases and
in hot countries, diarrhoea), in the scanty and high-colored urine, in
the nausea, the coated tongue and the bitter, mawkish taste which
takes possession of the mouth, in the aching and dizzy head, the pains.
in loins and limbs, and not unfrequently in that mental depression
which bespeaks a mind not less jaundiced than the body.
Diagnosis.—The symptoms above enumerated form a group suffi-
ciently suggestive and not easily mistaken. The patient will be sure,
and will assure the physician, that he has dyspepsia or is "bilious."
If, in his mind, it be the former, perhaps the word has a significance
wide enough to include the actual state of affairs; while the physician
is guided to a correct conclusion as to the precise pathological condi-
tion, not merely by the sensations which are referred to the right side,
but by the absence as well, notwithstanding the nausea and furred
tongue, of a distinctly gastric set of symptoms.
If the patient thinks himself "bilious," the word represents to his
mind a dim conception of an encumbered liver which is really not
very far from the truth; and though "bilious" patients are most tena-
cious of their own diagnosis, and are inclined to insist that the physi-
cian accept it without asking for particulars, yet a little patience and
skill will soon be successful in drawing out the details necessary to
settle the diagnosis. In very many cases a physical examination may
be considered a needless procedure; but in those instances in which
the subjective symptoms, plus the ochre skin and the blanketed tongue,
DISEASES OF THE ORGANS OF DIGESTION.
863
leave the diagnosis still a matter of doubt, percussion and palpation
will definitely decide the question. The patient should be placed upon
the back, the knees drawn up to secure the greatest possible relaxation
of the abdominal muscles, and the region in question thoroughly ex-
posed. Palpation will determine the lower margin of the liver to be
decidedly below the border line of the ribs, whereas it normally over-
steps that line very little, if at all. It will be felt as a smooth body of
firm consistence, following the respiratory movement of the diaphragm.
Percussion will also give its reliable testimony as to the increased size
of the organ. It will often show an extension of the liver clear across
the epigastrium and into the left hypochondrium. It should be borne
in mind, in employing this method of examination, that, at the lower
border of the liver, deception is possible through the resonance of a
gas-distended transverse colon, and that at the upper border there is
not the same clear definition of the margin, because the convex surface
of the liver fits into the concave base of the lung, thus causing the char-
acteristic percussion sounds of the two organs to shade off into each
other. It has been remarked, also, that in both percussion and palpa-
tion there is a possibility of mistake in those cases where the liver has
been forced downward, as, for instance, in pleuritic effusion, the lower
margin of the liver being thus found below its normal position, although
in fact there exists no enlargement. It might be urged in answer that,
by defining the entire gland, it would appear still unchanged in its
actual size, the depression above corresponding to the extension below,
and so the error would be excluded. But it certainly is not going too
far to assert that any changes within the thorax sufficient to produce
a displacement of the liver will be attended by symptoms of their
own, pronounced and grave enough to render a diagnosis of congestion
of the liver an almost inconceivable blunder.
Prognosis. Omitting those cases, already ruled out, dependent
upon obstructions of the chest circulation, the prognosis is favorable,
with a single exception. This exception applies to the cases which
are due to the use of liquors, continued in spite of the physician's pro-
test. The logical outcome of persistence in the habit is steady progress
toward cirrhosis and incurable degeneration; and the patient should
be led to anticipate this reasonably-to-be-expected result. But if he
be ready to relinquish his habit, the disorder not yet having passed
beyond congestion, the prognosis becomes as favorable as in those
cases consequent upon other causes.
Treatment. Treatment is almost purely medicinal. Aside from
the avoidance of dietary excesses, and the observance of those ordinary
rules of health which include a reasonable amount of physical exercise,
no accessory measures are employed. The proper medicinal agents
are reliable and efficient, their thorough work affording a striking con-
trast with the questionable results obtained from the crude make-shifts
864
A SYSTEM OF MEDICINE.
of purgatives, from the citrate of magnesia to blue mass, or of leeches
applied to the anus.
The leading remedies are Nux vomica and Cinchona.
The symptoms calling for Nux vomica are: liver swollen, indurated
and sensitive, with pressure, slight jaundice, nausea, constipation, ful-
ness in the head; complaint induced by high living.
Cinchona is especially valuable when the congestion occurs during,
or after, an attack of intermittent fever (arsenic); pain and swelling
in the region of the liver, sensitiveness to touch, yellowness of the skin,
nausea, and loss of appetite.
Hughes has good words for Iris vers. and for Sulphur. Ludlam
praises Ammonium mur. Jousset records a brilliant instance of perma-
nent cure, the disorder having existed for eight years, with Lachesis,
which is evidently a favorite remedy with him.
Sepia and Magnesia mur. are especially applicable to the congestion
dependent upon uterine conditions. The writer has used Euonymin
in some cases, with decidedly pleasing results. Other remedies which
may be consulted are: Bryonia, Chamomilla, Chelidonium, Hepar sulph.,
Leptandra, Lycopodium, Mercurius, and Podophyllum.
ICTERUS OR JAUNDICE.
Definition.-Icterus or jaundice is the diffusion of a peculiar col-
oring matter through various tissues, secretions, and excretions, in
consequence of hepatic derangement. The precise hue of the stain so
resulting is subject to wide variation, passing through all the inter-
mediate shades between a light yellow and a brown so dark as to al-
most suggest an admixture of black. Yellowish or brownish discol-
oration may show itself over limited areas of the skin when no jaundice
is present, as in the tingeing of forehead and cheeks which marks chlo-
asma, or the patches on the chest which appear in chromophytosis.
So it becomes necessary to specify, in defining jaundice, an exhibition
of coloring matter due to some disturbance of the liver, although with
certain fluids and tissues, as for instance the conjunctiva, no change
in color is known except the icteroid. An exact definition of this dis-
order cannot be one of close limitations, for it may be the expression
of numerous and widely differing hepatic conditions, and is, at best,
but a symptom. Still, it is a most prominent symptom, and is fairly
entitled to its place in the nomenclature of disease. Biliary discolora-
tion occurs in the course of such profound discases of the liver as acute
hepatitis, cirrhosis, and cancer, but is not the chief symptom. In these
cases it stands in the same relation to the disease in which sore throat
does to scarlatina. Because of the coexistence of the two latter, no one
thinks of denying the entity of pharyngitis.
DISEASES OF THE ORGANS OF DIGESTION.
865
Etiology.—Ligate the ductus communis choledochus in the living
animal, and in twenty-four hours jaundice is developed. Therefore,
jaundice may be caused by mechanical obstruction of the biliary pas-
sages; and clinical experience has shown obstruction to be the cause
in the majority of cases of this disease. But it is not the only cause,
for mental emotions, when their current was turbulent, have been
known to start this same process of yellow staining. Let us consider
for a few moments these two classes of causes which lie behind this
malady, the obstructive and the non-obstructive.
I. That obstruction of the bile-ducts should be followed by disten-
sion of so much of the biliary channels and receptacles as lie behind
the impediment, that this in its turn should favor the reabsorption or
dialysis of the bile through the coats of the vessels and back into the
blood-current, and that by aid of the circulation the bile should be
carried as a stain to all parts of the body, is not hard to understand.
Given the obstruction, and we should naturally anticipate just the re-
sult which experience shows to be the sequence in fact. So there is
left only the query: How do such obstructions occur? They are the
possible results of quite a variety of conditions. In the typical jaun-
dice, all inflammation and swelling of the mucous membrane lining
the ducts encroaches upon the normal calibre of the passages, and an
increased production of mucus suffices to plug the narrowed canal
altogether. A calculus formed in the gall-bladder may, in travelling
outward, block up the common duct; or these concretions may be
formed at the site of the obstruction. The same occlusion may occur
from the presence of hydatids and of lumbricoid worms. The exuda-
tion of coagulable lymph may end in its organization and a consequent
stricture. External pressure, proceeding from an accumulation of the
contents of the colon or from the gravid uterus, may embarrass the
biliary duct. This pressure may even be exerted by enlarged lym-
phatics of this region, occurring as an incident of depraved or malig-
nant cachexia. Or cicatricial tissue, the result of ulcerative processes
within the duodenum, may involve the opening through which the
products of the liver find their way into the intestine, and thus cause
retention. Those diseases of the liver involving the organ in profound
tissue changes not unfrequently set up an obstructive jaundice. It is
even asserted that tumors of the ovaries, of the kidneys, of the pan-
creas, and of the pylorus, may exercise sufficient pressure upon the
channels through which the bile should flow, to send it back into the
circulation.
II. Coming now to the second class of causes, those in which there
is supposed to be no mechanical obstruction to the discharge of the
bile, yet which are sufficient to bring about the characteristic yellow
staining, we find the utmost confusion and divergence of opinion pre-
vailing. Where is the bile pigment originally formed? Is it manu-
VOL. I.—55
866
A SYSTEM OF MEDICINE.
factured by the liver? Or does it preëxist in the blood, being merely
filtered out by the liver? Does the liver fail to strain it out of the
blood, or fail to manufacture it? Does the blood normally receive a
certain amount of bile from the liver or intestines to be immediately
oxidized, and does a depraved condition of the blood allow it to circu-
late unchanged? Might a decrease of tension in the portal vein by the
laws of hydraulics cause the bile to flow backward in its channels toward
the hæmatic capillaries, and so induce reabsorption? Does the hæm-
atin of the blood ever undergo a metamorphosis into a yellow pigment
resembling, or identical with, the coloring matter of the bile, thus
giving rise to a jaundice which is a blood disease? These are some of
the questions which are, as yet, undetermined, and which serve to
make the second class of causes uncertain and hypothetical.
Virchow has been the champion of the theory that morbid altera-
tion of the hæmatin of the blood is a cause of non-obstructive jaun-
dice. The familiar exhibitions of color in the extravasation of blood
attending a bruise, the yellow surface of the newly-born, with whom
the fulness of the peripheral capillaries results in the deposit of a cer-
tain amount of hæmatin, even the yellow sputa seen at times in pneu-
monia, have all been brought forward in support of this notion. Were
this view to meet with common acceptance, the jaundice resulting from
the serpent poisons, from phosphorus poisoning, and from pyæmia,
would probably be referred to this blood alteration for their explana-
tion. But even Virchow has retreated somewhat from his original po-
sition, being now inclined to credit to catarrh of the biliary ducts.
(that is, to an obstructive cause) many of the cases he would formerly
have assigned to changes in the composition of the blood.
The opinion that in the healthy organism more or less bile finds its
way into the blood, there to be consumed, and that jaundice may
result from failure to properly dispose of the bile received, is sup-
ported by Frerichs. He also favors the theory that changes in the
equilibrium of pressure among the circulation of the liver may send
the bile into the blood-current instead of into its proper receptacle.
The supposition that bile, or at least its pigment, finds its origin in the
blood, and is only eliminated by the liver, is too violent an assault
upon the commonly received notions concerning the hepatic functions
to deserve to stand in the face of the fact that extirpation of the liver
is not followed by accumulation of pigment in the system. Yet there
are not wanting those who maintain this hypothesis in explanation of
non-obstructive pigmentation.
It is hardly worth while to enter into the discussion as to the bile
acids, where they are formed, and whether, or not, they appear in the
urine during jaundice. For the real question does not refer to these
acids, but is concerned with the coloring matter; and up to the pres-
ent time evidence has not been obtained adequate to settle the vexed
DISEASES OF THE ORGANS OF DIGESTION.
867
questions in regard to its normal and abnormal presence in the blood
current. Enough has been said to indicate the problems which are
presented by non-obstructive jaundice, together with the various theo-
ries which have grown up around them in attempted solution. With
these speculations before us we may easily divine what was in the
minds of those who have, from time to time, suggested probable causes
and possible explanations of their modus operandi. The list of causes re-
ceiving common acceptance, as being the more probable and reasonable,
includes absorption of bile from the intestines, as a result of violent
mental emotion or of habitual constipation; absorption from the liver,
in consequence of derangement of the hepatic circulation; absorption
from either liver and intestines, or from both, of a part of the product
of a liver secreting an excessive amount of bile; failure of the liver to
manufacture the bile; failure to strain it out from the blood where it
pre-exists; failure of the blood to carry on the metamorphosis of bile
normally present in its current, and the toxic conditions consequent
upon the presence in the system of serpent poisons, malaria, phospho-
rus, and the existence of pyæmia.
Of course, these poison-states are supposed to result in jaundice by
bringing about some one of the conditions above enumerated. Under
certain circumstances, the causes, or some of them, tending to produce
this disease, may act with sufficient uniformity to produce a preva-
lence of the disorder which raises it to the dignity of an epidemic. The
official reports of the Rebellion show that 10,929 cases occurred during
one year in those portions of the Northern army which were stationed
in miasmatic localities.
Pathology. It has been seen, then, that jaundice arises from me-
chanical obstruction to the passage of bile into the intestines, and the
consequent reabsorption of the detained fluid into the blood; or from
the suppression of the biliary secretion arising from some morbid con-
dition of the liver itself, whereby biliary ingredients accumulate in the
circulation.
Some of these ingredients or constituents of bile are generated in
the liver itself, as the bile acids, while others, as the green bile pigment,
or biliverdine, and the cholesterine exist preformed in the blood. In
obstructive jaundice there may be a congenital deficiency of bile-ducts
or an accidental obstruction; non-obstructive jaundice may result.
from innervation, disordered hepatic circulation, or an absence of
secreting structure.*
Non-obstructive jaundice is characterized by the rapid accumula-
tion of green bile pigment in the blood, until the serum, the tissue,
and the urine are saturated with pigment.
Over this secretion the mental state seems to exercise a remarkable
influence, so much so that mental emotion favoring congestion of the
* Harley on Jaundice, p. 20.
868
A SYSTEM OF MEDICINE.
organ favors the stoppage of the secretion. Obstructive jaundice
is also characterized by the accumulation of pigment in the blood,
whence it stains the tissues, the urine and the serum. The bile, in
these cases, is absorbed from the distended ducts and gall-bladder;
and the biliary products, manufactured in the liver, equally with those
formed in the blood, find their way back into the circulation, to be
eliminated by the excretions. Hence, the bile acids, which are absent
in non-obstructive jaundice, are present in this form, from reabsorp-
tion, as well as the bile pigment (Harley).
The anatomico-pathological changes found are in the liver itself
and in distant tissues and organs.
The size of the liver is usually increased, but its form is not altered,
and the bile-ducts are more or less dilated and distended with bile in
the obstructive variety.
In the non-obstructive form, the liver is not so large and the ducts
are collapsed, and they and the excretory passages are quite pervious.
The color of the liver in the obstructive form is deep yellow and, in
the highest grades, olive green, usually presenting a mottled appear-
ance; the hepatic cells grouped round the intra-lobular veins, tinged
or clotted with bile pigment; the nucleus is sometimes dyed yellow;
the peripheral cells of the lobules are pale or scarcely tinged.
After obstruction has lasted for some time, the liver cells contain firm
collections of pigment in the form of yellow, reddish-brown, or green
rods, spheres or angular fragments, which lie in the minute network of
the capillary ducts, and sometimes form casts of the capillary network.
In old cases the liver becomes atrophied and acquires a dark green
or even black color, and loses its consistence, becoming soft and disin-
tegrated from breaking-up of the hepatic cells. This condition is not
present in non-obstructive jaundice.
Bile pigment is found in nearly all the organs and fluids. Besides
the characteristic color of the skin, conjunctiva and urine, as soon as
the body is opened we notice the lemon color of the fat in the sub-
cutaneous pericardium and elsewhere. The fibrinous coagula in
the heart and blood vessels, the fluid in the pericardium, and any
pathological transudations or exudations of the pericardium, pleura
and peritoneum have a distinctly jaundiced appearance. The less
red the normal color of the different tissues is, the more marked is
the pathological yellow color; hence, it is more evident in the serous
and fibrous membranes, the walls of the vessels, the bones, cartilages,
etc., than in the muscles, spleen, etc. The skin is most affected, the
pigment being deposited in the deeper layer of the epidermis, giving
rise to all grades of color, from a slight yellow tinge to an intense saf-
fron color, and, in malignant jaundice, to a greenish or even mahogany
* Niemeyer's Practical Medicine, vol. i., p. 107.
DISEASES OF THE ORGANS OF DIGESTION.
869
color. The brain and nerves show little color, and the mucous mem-
brane scarcely any.
The color of the urine becomes changed at an early period, from
the admixture of cholepyrrhin. "It becomes saffron-yellow, reddish-
brown, dark brown, greenish-brown, or brownish-black, according to
the quantity and quality of the pigment which enters into it."* In the
earlier stages the kidneys are often enlarged and congested, and the
secreting cells loaded with bile. In old and intense cases the kidneys
are of an olive-green color, and some of the uriniferous tubules are
filled with a brown or black deposit. Upon close inspection the pale.
uriniferous tubules are found to be of a green or brown color, and
their epithelial lining, which is seldom entire, is of a deep-brown
tinge, which is particularly marked in the nuclei; the dark uriniferous.
tubules are distended with a coal-black, hard, brittle mass, which may
or may not be soluble in caustic potash. In addition, there may be
noticed cylindrical masses, consisting of an amorphous material, brown
in the centre, but becoming gradually paler towards the periphery.†
Next to the kidneys the sweat-glands are most involved, the sweat
often coloring the linen distinctly yellow.
Symptomatology. The one symptom which outranks all others.
in prominence and which gives the malady its name, is the familiar
yellow coloring of various tissues and secretions. There is hardly a
fluid or a tissue which may not be tinged with this pigment, though
the mucous membranes are by some held to be exempt, and certainly
are not a favorite place for this deposit. The skin offers the largest
opportunity for its display. Here its slightest touch is a light yellow,
which may progress into a darker yellow, and then pass through the
various shades of greenish-yellow into the browns, and almost up to
the boundary line of black. A large amount of the bile pigment
passes through the kidneys, the urine being the first to show the pres-
ence of free coloring-matter in the system, and here the changes of
color are rung principally upon the browns.
The prevailing saffron hue early invades the conjunctiva, which, in
common with the urine, receives the stain in advance of the skin. The
sweat-glands carry off the pigment in such appreciable quantity that
the linen is perceptibly stained, especially in the region of the axillæ.
In rare and severe cases yellow milk, yellow tears, and even yellow
vision have been observed.
Naturally enough, the scattering of the bile pigment over the entire
organism leaves little or none for the fæces. When the diversion of
biliary matters from their proper channels is but partial, the stools
show only a lessened color. But in the cases in which this diversion is
more nearly complete, the alvine evacuations assume a color which
* Frerichs, Disease of the Liver, William Wood & Co., 1879, p. 70.
Frerichs, op. cit., page 72.
870
A SYSTEM OF MEDICINE.
has been compared with that of slate, of lead, of clay, and of ashes,
and which may, at times, almost approach a white. The usual ten-
dency is toward a moderate degree of constipation, though occasional
cases tend toward diarrhoea.
Although there is little febrile motion accompanying this disorder,
the pulse does not by any means hold on its undeviating way, unaf-
fected by the disturbance below the diaphragm. The influence exerted
upon the circulation by the presence of bile in the blood current is
not a little remarkable. The, sedative effect is unmistakable, the fre-
quency of the pulse dropping decidedly below the normal rate, in
some cases going as low as forty beats per minute, and even lower.
Whether, or not, this is due to depression of the heart, as has been
supposed, is uncertain. At any rate, no special danger is indicated by
this symptom, for the prognosis of jaundice is, in the main, good.
Pruritus is often present, the itching extending over large areas of
the skin, and at times rising to a height which becomes intolerable.
The lesser symptoms are: loss of appetite, coated tongue, bitter taste,
nausea, headache, vertigo, drowsiness, and the malaise which ushers
in and accompanies the attack.
In severe and fatal cases dysenteric symptoms and hæmorrhages
from the stomach or intestines are sometimes met; while in others the
nervous system bears witness to the heavy incubus under which it
labors by sopor, delirium, and coma. If the disease be sufficiently
protracted, the disturbance of the digestive function is plainly written
in the pinched and haggard features.
Varieties. In considering the causes of jaundice it became neces-
sary to advert to conditions which might, with equal propriety, be
canvassed under the head of varieties; for the simplest and most nat-
ural, and therefore best, classification includes but two varieties, the
obstructive and the non-obstructive. Perhaps a third class might be
added to cover the jaundice of the newly-born, which is the result of
a deposit of hæmatin. The division into jaundice from reabsorption
and jaundice from suppression is not nearly so good, as it begs the
whole pathological question involved.
Many writers speak of "malignant jaundice." This will be consid-
ered under its appropriate heading of acute yellow atrophy. Though
there has been some confusion regarding the two, the best opinion
makes them identical; and under this ruling there is properly no
such variety of jaundice as the "malignant." Varieties have also been
created based upon the amount of coloring-matter at large in the
system. This classification is usually made to embrace three forms,
the yellow, the green, and the black. Some authors also mention the
"epidemic" form; but all these refinements are fanciful rather than
practical, and tend not to increase but rather to obscure understanding.
Diagnosis. There is almost nothing in the entire field of diagnosis
DISEASES OF THE ORGANS OF DIGESTION.
871
easier than the recognition of jaundice. Spreading, as it does, its most
important symptom over the entire surface of the body, it is hardly
possible that it pass unsuspected, as, for instance, might be the case.
with an hepatic abscess, hidden away in the body of an interior organ.
The yellowness will be seen, it cannot be overlooked. On the other
hand it is so far characteristic that, when seen, it can scarcely be con-
founded with the signal of any other disease; so that in both direc-
tions the liability is at the minimum.
Chlorosis, and the cancerous dyscrasia, may spread a light-yellow
tint over the skin, but they leave the conjunctiva intact. And beyond
these two there is nothing which even a lively imagination can suggest
as offering a possibility of mistake. When, however, jaundice is recog-
nized, the work of diagnosis is not necessarily at an end. The ques-
tion is: Is this symptom the symptom and the disease, or is it a symp-
tom of some other disorder, and nothing but a symptom? If it be
the result of the impediment offered by a gall-stone, or of the patho-
logical conditions obtained in acute yellow atrophy, it is not the dis-
ease, but a symptom. It would be out of place to here detail the
diagnosis of these, and other, hepatic disorders; they will be found in
their proper place. Whether the trouble be less than, or altogether.
different from, jaundice is germane to the present purpose, and is
easily decided. Whether it be jaundice, but at the same time much
more than jaundice, involves the whole subject of hepatic diseases, and
cannot be included here.
It must be understood that, though the diagnosis may be easy, jaun-
dice is after all but the name of an inaccuracy, for it must cover
pathological conditions differing widely, conditions of whose precise
existence we cannot be exactly informed, and about which we can do
little more than group plausible theories.
Prognosis. It is not often that jaundice has a fatal termination,
and little fear need be felt for the patient's life. But caution must be
observed in giving an opinion as to the probable duration of the
attack. Ordinary cases may be comprised within a period of from
one to four weeks, while not unfrequently the disease is prolonged
over a period of time measured by as many months, and has been
known to persist for years. When it results from the more occult
causes, being due to some ill-understood loss of balance among the
forces of the system, it is quickly at an end. When it is of the ob-
structive or semi-obstructive variety, as, for instance, partial occlusion
of the bile-ducts from catarrh of their mucous lining, the tendency is
toward a longer duration. As must obviously be the case, when a
favorable termination is approached, the stools resume their normal
color before the skin loses its stain, the bleaching of the cutaneous
surface being a matter not of abrupt, but of gradual change. In
those rare and exceptional cases in which the kidneys seem to take
872
A SYSTEM OF MEDICINE.
on a form of congestion, and we have the grave nervous symptoms
passing into delirium, convulsions, and sopor, it goes without saying
that the prognosis is bad, and the end death. But in general the
prognosis is decidedly favorable.
Treatment. This is accomplished exclusively by the internal
administration of the appropriate medicines. There is no auxiliary
or adjuvant treatment, partly because internal remedies are the only
available agents, partly because the jaundice which really constitutes
a disease is often confounded with the jaundice which is but a symp-
tom of a much deeper disorder, and last, because the less accurate the
knowledge of any malady the greater the number of remedies which
are brought forward as infallibly curative.
Sifting out the remedies which have best stood the test of actual em-
ployment, and taking them up in the order of their importance, the
following can be warmly recommended.
China. Its symptoms are nausea, with canine hunger, aversion to meat, oppres-
sion of the stomach, bitter taste, dryness and roughness of the skin, clay-colored fæces.
It is especially indicated if the disease occurs in the course of, or after, malarial fevers,
or when it follows excessive loss of the fluids of the body.
Nux vomica is more particularly adapted to jaundice caused by catarrhal in-
flammation of the lining membranes of the hepatic ducts. The liver is swollen, and
there is some constipation of the bowels with the characteristic clay-colored stools;
dyspeptic symptoms are prominent.
Mercurius is appropriate to jaundice with fever. The stools are more liquid
and of a darker color than is usual in the disease. There is also more catarrhal in-
flammation, with loss of appetite and thickly furred tongue. In jaundice of young
children mercury is especially useful.
Phosphorus and Phosphoric acid.-The evacuations are diarrhoeic.
These are the remedies which have been tried and found useful in
England, Germany, France, and this country. Many others have
warm advocates. E. M. Hale thinks eighteen of his new remedies ap-
propriate here. Jahr would commence with Aconite whenever the
slightest excuse can be found for so doing; and Jousset thinks he has
known of some cases of cure of malignant jaundice (if the term be al-
lowed) through the use of this drug in the tincture. Hempel lays
special stress upon Podophyllum and Digitalis. In England, Hughes
is not satisfied until he has included Chamomilla, Chelidonium, Hy-
drastis, Podophyllin, Leptandra, Myrica cerifera, and Crotalus. He
also speaks of two striking cases of cure by Iodum. Any one of these,
and other, remedies may be indicated by the totality of symptoms,
but it is impossible to follow the list further than the few whose value
is beyond dispute.
To attempt to do more than this would open the way for a flood of
drugs, the indications for which could be little more than a repetition
of familiar landmarks of materia medica, in no wise specially related
to the disease we have been considering.
DISEASES OF THE ORGANS OF DIGESTION.
873
BILIARY CALCULI.
Synonyms.-Cholelithiasis, Gall-stones.
Definition.-Biliary calculi are concretions formed in the gall-
bladder and bile-ducts, resulting from the precipitation of certain sub-
stances held in solution in the bile. They differ in number, size, form,
color, and in chemical composition.
The number of calculi found in the gall-bladder is very variable, rang-
ing from one to several hundred. In some instances the number is
enormous.
Frerichs found 1950 in a woman sixty-one years old; Dunlop, 2011
in a woman ninety-four years old; Morgagni, 3000; Hoffman, 3646;
Otto, 7082 in one gall-bladder.
When a large number are found in one bladder, they are alike in
size, shape, and chemical composition.
As a rule, from four to eight are found together; the single stone is
the exception. When but one is found, it is usually of large size,
sometimes completely filling the bladder.
The size depends upon the number. When numerous, they are quite
small, varying in size from a mustard-seed to a small pea.
The fewer the number the larger the size, and conversely, the greater
the number the smaller the size. The larger stones are generally found
in the gall-bladder. Very large stones are rarely seen. Frerichs men-
tions having seen several from two to two and a half inches long, and
one inch in thickness. Another is described as three inches in length,
and one and one-half inches in diameter. The largest one ever re-
corded measured six inches in length, and two and one-half inches in
diameter.
When gall-stones are very minute in size and very numerous, they
are called gall-gravel. Von Schueppel remarks that it occurs in con-
nection with larger concretions, though also often found alone. Some-
times it is crystallized and granular, sometimes pulpy, consisting of
mere inspissated bile. Cruveilhier once found the biliary passages
from the ductus choledochus to the finest bile-ducts enormously dis-
tended and filled with such gravelly masses through which the bile
flowed as through a sand filter.
The shape of gall-stones varies as much as the size. The solitary
stones are generally round or oval. When numerous, they are rounded
or many-sided, with facets produced by attrition with each other.
Square, pyramidal, and wedge-shaped stones are also often found.
In the bile-ducts the stones sometimes assume a cylindrical shape, or
branch out like coral formations.
The color of gall-stones varies from grayish or pearly white to black,
presenting in mixture many gradations of color between. The majority
874
A SYSTEM OF MEDICINE.
of them are brown or yellowish-brown. The color depends upon their
chemical constituents, but the coloring matter of the bile forms the
basis of each tint. Generally they are opaque, except those composed
of cholesterine, which, when fresh, are sometimes transparent.
The surface is generally smooth, but occasionally rough, wrinkled,
or nodulated. To the touch they are sometimes soft and slightly
greasy, at other times hard and rough.
The consistency is usually slight. They may easily be cut or broken
down with a slight pressure. They are readily broken down by attri-
tion with each other. In rare instances they are firm and hard, offer-
ing considerable resistance to attempts to crush them. The specific
gravity is greater than water when they are in a fresh state, but usually
less when dried. Some varieties which contain a considerable propor-
tion of salts of lime have a specific gravity nearly twice that of water.
Structure.-Von Schueppel classes gall-stones under two varieties,
namely, first, simple homogeneous stones, and second, compound nu-
cleated stones. The homogeneous stones are of comparatively rare
occurrence. They are of uniform structure, and on fracture show a
crystalline, earthy, or soap-like formation. The stones having a crystal-
line structure are composed almost wholly of cholesterine. Those with
an earthy or soap-like fracture are composed of cholesterine, biliary
fats, earths, and salts of lime.
Compound nucleated stones.-These, as the name implies, are com-
posed of different chemical compounds arranged in layers or mixed
together. They generally consist of three parts, namely, a nucleus, a
body, and a crust or cortical portion. The nucleus is usually of a
brown or black color, of small size, of varying degrees of consistency,
and is composed of a small quantity of biliary coloring matter and
lime compound, bound together by mucus. Occasionally it is formed
of cholesterine crystals or, more rarely, of some foreign body which has
found its way into the bile-ducts, as a grape-seed, a minute clot of
blood, or an intestinal parasite. In some instances the stone has
more than one nucleus. Stones having several nuclei are probably
formed by the agglutination of several small ones. Cases are recorded
in which the nucleus consisted of a needle, a globule of mercury, and
a plum-stone respectively.
The body lies between the nucleus and crust, but is not unfrequently
wanting. It generally presents a striped and radiated appearance. It
is sometimes arranged in concentric layers, and sometimes appears to
be homogeneous and of an earthy or watery consistency. The body
is of a lighter color than the nucleus, particularly when composed of
cholesterine which, when present, gives it a glistening crystalline ap-
pearance.
The crust or cortical portion differs from the body in color, hardness,
and structure. It consists of successive layers, the number of layers
DISEASES OF THE ORGANS OF DIGESTION.
875
being more numerous in stones which have existed for some time.
The hardness and color vary in different stones according to their
chemical composition. If the crust is composed of cholesterine, it is
arranged in smooth layers of a pearly lustrous appearance, and varies
in color from almost white to a greenish-gray. Biliary coloring matter
and lime-compound forms a very hard, smooth crust of a greenish-
black hue. When carbonate of lime constitutes the bulk of the crust,
it forms a thick brown coating, either smooth or uneven and warty
looking.
In many cases, however, the crust shows no regularity of form or
structure, the several substances composing the stones being inter-
mingled in all varieties of form and appearance.
Chemical Composition.-The principal chemical constituents
found in the gall-stones are, in the order of their frequency and pro-
portion, as follows: cholesterine, biliary coloring matters, biliary acids
and salts, lime, and carbonic acid. Other substances more rarely
found are fatty acids, soda, magnesia, iron, manganese, and copper.
Mucus and epithelium also constitute a small part.
Cholesterine is the principal constituent of most gall-stones, many
being formed almost entirely of it, and nearly all containing some pro-
portion of this substance. Cholesterine stones are of a pearly, trans-
lucent appearance, of a white or yellowish color, crystalline in frac-
ture, and of a radiated structure. They are of light specific gravity,
soapy to the touch, and often of large size. In many cases choleste-
rine is combined with more or less of biliary coloring matter, or with
lime and magnesia. In these combinations they are darker in color
and of greater specific gravity. The bile pigment is sometimes dis-
tributed irregularly in the cholesterine, giving the stone a striped or
mottled appearance, or of alternate layers of light and dark color.
Biliary coloring matters are the next most common ingredients, and
are found in variable quantities in nearly all gall-stones. Biliary acids
and salts, and the fatty acids, are found in small quantities. They
are more frequently present in combination with lime than in any
other form.
Lime is the chief inorganic element which enters into the composi-
tion of gall-stones. It is usually in combination with other elements,
but particularly with carbonic acid.
The different combinations and proportions of all these substances
account for the great variety of stones and their different physical
conditions.
Classification.-The classification found in Ziemssen, vol. ix.,
page 698, is the simplest, and at the same time the most comprehen-
sive. It arranges them according to their chemical composition.
A. Concretions containing cholesterine. These are again divided
into
876
A SYSTEM OF MEDICINE.
1. Pure, simple, cholesterine stones.
These are generally single, or there are but few together, and on the
whole they are not very frequent. They are rounded, of the size of a
pea to a large cherry, of a glossy transparency, colorless, or of a faint.
grass-green; their surface is smooth, or granulated, or nodular; their
fracture shows radiated crystalline plates, and is therefore glistening.
They are of light specific gravity, not hard, and easily cut.
2. Mixed cholesterine and pigment stones (with a slight admixture
of salts, etc.).
This is the commonest form, several or even many being found to-
gether, of all sizes and shapes. They are often faceted, are externally
of a brown or green color, or are covered with a pearly, shining,
smooth coating of cholesterine. Their fracture shows concentric layers
of changing color and different degrees of lustre. They often possess.
a crust of lime and pigment (hard, dark green, smooth), or of carbo-
nate of lime (white), which sometimes forms a uniform smooth cover,
sometimes appears in coarser crystalline clusters, rough and jagged
masses. Aside from this lime crust, these stones are of light specific
gravity, and quite soft.
B. Concretions destitute of cholesterine. Of these there are two va-
rieties, viz.:
1. Pure, simple pigment-stones.
These are not especially frequent. They are very small, often
gravelly, generally occurring in large numbers. The larger ones are
mulberry-shaped, blackish-green, shining like tar; their fracture is
likewise so, and they are homogeneous. They are not very firm, and
their specific gravity is light. They are notable for the amount of
copper they contain.
2. Simple lime-stones (carbonate of lime).
These are very rare, are single, of heavy specific gravity, very hard,
and of a whitish-gray color. Their surface is rough or even slightly
warty.
Origin of Gall-stones.-It is evident that all the constituents of
gall-stones must exist in the bile, and that these constituents are in a
soluble state.
By some process of precipitation they are thrown down and aggre-
gate into the mass constituting a gall-stone. There seem to be three
conditions requisite to the formation of biliary calculi.
1. An excess of certain elements of bile so great that they cannot
be held in solution, and are consequently precipitated.
2. The natural solvents, such as soda, may exist in insufficient
quantities to hold other elements in solution.
3. An interruption or retardation of the flow of bile, thereby favor-
ing a precipitation and agglomeration of the constituents which enter
into the formation of stones.
DISEASES OF THE ORGANS OF DIGESTION.
877
It is doubtful if concentration or inspissation of the bile conduces.
to the formation of gall-stones, for this does not diminish the capacity
of the bile to hold in solution the substances constituting gall-stones.
Etiology. The chemical changes which lead to the formation of
gall-stones have already been briefly detailed, but other conditions
affecting the individual may be regarded as predisposing and exciting
causes of their formation.
Chief among these may be mentioned age, sex, habits of life, climate,
and affections of the liver and bile-ducts.
Gall-stones are much more frequent in middle and advanced life
than in youth and childhood. They are of comparatively rare occur-
rence prior to the age of twenty-five; they are exceedingly rare in
infancy and childhood. Of 395 cases, only three were persons under
twenty years of age.
The liability to them increases with advancing years. In old age
there is a greater proportion of cholesterine in the bile, less activity of
the biliary secretion, and retardation of the flow. These conditions
combined may be considered predisposing causes.
Women are more subject to gall-stones than men, the proportion
being as three to two. There seems to be no reason for it in any
sexual peculiarity, and the most plausible explanation of their more
frequent occurrence in women lies in the fact that women live much
more sedentary lives than men.
Corpulent and sedentary people are thought to be more liable to
cholelithiasis than those of active habits, because inactivity promotes
stasis of the bile, and consequently the precipitation of the substances
composing biliary concretions.
The effect of climate cannot with any certainty be determined. In
hot climates, when excessive heat predisposes to excessive secretion and
active flow of bile, it would be expected that the formation of gall-
stones would be of less frequent occurrence, but no accurate statistics
have corroborated the supposition.
Catarrh of the gall-bladder and biliary ducts, anatomical changes in
the liver hindering the excretion of bile, hereditary predisposition,
constitutional tendencies, luxurious habits of living, and, finally, too
long abstinence from food, have, by different observers, been regarded
as ætiological factors in the production of biliary calculi.
According to Dr. Goodeve, the consequences and effects of biliary
calculi may be arranged under the following heads :
1. They may remain stationary in the ducts or gall-bladder with-
out causing much inconvenience. It is rare, however, that they do
not cause some disturbance, though it may not have attracted notice.
2. They may pass from the branches of the ducts or gall-bladder
by the common duct into the duodenum, causing in their passage
slight or severe disturbances of the system.
878
A SYSTEM OF MEDICINE.
3. They may be arrested in their passage and act as plugs, com-
pletely or partly obstructing the channel in which they are stopped,
sometimes causing obstructive jaundice or even permanent closure
of the duct, with the usual symptoms and consequences.
4. They may become encysted or, at any period of their existence,
give rise to degeneration of neighboring tissues, inflammation, suppu-
ration, softening, ulceration, pyæmia, or even rupture or perforation
of the structure in which they lie, leading to extravasation of the con-
tents, or giving rise to fistulous passages by which the calculus may
escape.
5. Arrived within the intestinal canal, they may be ejected with the
evacuations, or they may be arrested in some part of the canal caus-
ing obstruction with the pneumonia, or other mischief resulting
therefrom.
Symptomatology.-The symptomatology of gall-stones may be
considered under two heads-the symptoms which arise from the
presence of gall-stones in the gall-bladder and ducts, and the symp-
toms which are produced by their extrusion from the gall-bladder and
biliary ducts.
Gall-stones in considerable numbers may remain in the gall-bladder
for an indefinite period without causing much inconvenience. The
patient may be even unconscious of their presence. This is particu-
larly the case with persons of advanced years, on account of the great
tolerance to their presence which is shown by the parts in old age. If,
however, they are present in large numbers they frequently cause a
feeling of discomfort and uneasiness together with a sensation of ful-
ness and distension in the region of the gall-bladder. The patient is
more liable to be thus affected after active exertion, or when the
stomach is distended by a full meal. If the gall-bladder is much dis-
tended with calculi, it sometimes forms a tumor which may be felt
through the abdominal walls. The pressure of such a tumor upon
the pyloric orifice of the stomach may also produce irritation of the
nerves of the stomach, giving rise to various symptoms expressive
of gastric disturbance. In other cases the irritation caused by their
presence in the gall-bladder and biliary ducts may lead to inflamma-
tion, and subsequently to ulceration.
The inflammation may be of a mild form, causing no great amount
of pain, and end in the stone becoming encysted. In still other cases
the inflammation may eventuate in suppuration within the gall-bladder
and consequent distension of that viscus with purulent fluid. If in-
flammation occurs in the hepatic ducts, abscesses may form in neigh-
boring parts of the liver. In some instances, ulceration and softening
of the adjacent tissues take place, and the stone may escape from its
bed into neighboring parts. Occasionally a stone makes its way by
an ulcerative process into the stomach, duodenum, or through the ab-
DISEASES OF THE ORGANS OF DIGESTION.
879
dominal walls. In one instance a calculus escaped into the cavity of
the thorax.
At a recent meeting of the Cambridge Medical Society a case was
related of gall-stones discharged through an abscess in the right groin.
It occurred in a woman, who had an obscure swelling in the right
inguinal region. An exploratory puncture discovered pus too thick
to flow through the canula, but a free incision let out thick pus
and over a hundred gall-stones. The finger passed into the wound
in the direction of the gall-bladder; a large drainage-tube was then
tied in the opening, through which gall-stones still pass. There was
no bile and no fæcal odor. The patient had a remarkable history.
She was for several years subject to attacks like ague. One year be-
fore, she first noticed in the right side of the abdomen a swelling which
enlarged painlessly until it could not be spanned by her hand; her
bowels were regular, and she had no jaundice. Two months later the
swelling appeared, from her description, to burst inside her, and she
was immediately seized with violent cramp-like pains in the right
lumbar and iliac regions. The swelling diminished, and she had now
attacks of vomiting of dark fluid every five minutes for five days, and
during this time she ate nothing. When the vomiting ceased, how-
ever, she had a ravenous appetite, and was able to walk about. Alto-
gether, she had five similar attacks of vomiting, lasting from three to
five days each, followed by several weeks of health. The narrator
also mentioned a case of three fistule of the gall-bladder which led
respectively to the duodenum, colon, and skin.
In general, however, gall-stones remain quiescent in the place of their
formation, and induce but little, if any, disorder of the system unless
the number is large. It is when they are set in motion, and advance
from the gall-bladder or the place of their formation in the bile-ducts
to the intestinal canal that they give rise to severe constitutional dis-
turbance.
The passage of a gall-stone from the gall-bladder or bile-duct into
the duodenum occasions a series of symptoms which is designated
biliary or hepatic colic. If the stone is situated in the gall-bladder, it
is carried into the cystic duct, passes along the cystic into the ductus
choledochus, and finally, if not arrested in its course, makes its exit
into the duodenum. It is not clearly determined what are the forces
which set the stone in motion. It is probably a combination of
agencies, any one of which may be insufficient, but all of which, acci-
dentally combined, are effective. An unusual flow of bile conjoined
with a favorable position of the body, a sudden contraction of the ab-
dominal muscles, as in the act of defecation, or a violent fit of cough-
ing, carries the stone into the entrance of the cystic duct. It is more
easy to understand the causes which set in motion stones lying in the
hepatic ducts. Unless they lie in pouches in the ducts, there is no
880
A SYSTEM OF MEDICINE.
special hindrance to motion, except great size or adhesion to the
walls of the ducts. An unusual flow of bile or a sudden shock is
sufficient. After the stone has been set in motion, it is forced onward
by the pressure of bile behind it, and possibly by some contraction of
the ducts.
The passage of a gall-stone through the ducts is not always attended
with an attack of hepatic colic. The smaller concretions are frequently
expelled without any sense of discomfort. After the ducts have been
dilated by the passage of several stones, others may subsequently pass
unobserved, owing to the greater diameter of the ducts. Von Schuep-
pel observes that stones of considerable size may, in the case of aged
and sluggish individuals, pass wholly unnoticed. It is therefore when
the canal is smaller than the calculus, and sensitive to dilatation, that
the symptoms characteristic of hepatic colic occur.
The attack may come on suddenly or be preceded for several hours.
by slight nausea and feelings of uneasiness and distension of the ab-
domen.
Quite suddenly, or after a period of uneasy sensations referable to
the epigastrium and right hypochondrium, the patient is seized with
acute pain. The pain is referred to a spot to the right of the epigas-
trium and lower part of the chest, and radiates from thence to the
right hypochondrium, the right shoulder-blade, the spine, and even
to the right arm. It comes in paroxysms of great severity, increasing
in intensity with each recurrence, with intervals of abatement of suf-
fering.
The pain is described as most agonizing. It is of a burning, tearing,
boring, cutting character. The patient clutches at the epigastrium,
doubles himself up, contorts himself into all positions in the vain hope
of finding relief. Between the torturing paroxysms the pain is of a
dull, steady, burning character.
The expression of the patient is one of acute suffering. The coun-
tenance is pale and distorted, the pulse feeble, the skin bathed in cold
perspiration. In women of a delicate nervous temperament an attack
of hepatic colic sometimes causes hysterical or epileptiform convul-
sions, syncope, or delirium.
In some instances repeated and severe attacks are followed by
collapse and death. In such cases the countenance is ghastly pale,
the pulse weak and thready, and the body covered with cold clammy
sweat.
Hepatic colic is usually accompanied by repeated attacks of vomit-
ing. In a majority of cases the paroxysm of pain commences two or
three hours after eating. The contents of the stomach are first ejected,
succeeded by vomiting of a ropy, acid, colorless fluid. In mild cases
there may be only retching and vomiting.
The act of vomiting is usually followed by a remission of pain. If
DISEASES OF THE ORGANS OF DIGESTION.
881.
bile is present in the matter ejected, it is indicative of non-closure of
the common duct.
Fever is not, as a rule, observed in hepatic colic. The temperature
is not raised nor the pulse increased in frequency. On the contrary,
in the majority of cases the pulse is retarded, especially when the
stone is delayed in its progress for any considerable period, causing
obstruction of the hepatic or common duct. Wolff observed that
even in cases in which there is no jaundice the pulse is often from
five to ten beats slower than normal.
In the cases in which fever is present, it is generally caused by in-
flammation resulting from laceration of the bile-ducts.
Jaundice is present in a certain proportion of cases. Should the
attack last less than twenty-four hours, jaundice is not likely to occur.
Neither will there be jaundice if the calculus is arrested and delayed
in the cystic duct, or even in the common duct, if the stone is irregular
in outline and permits the bile to escape by its sides. But if the stone
is retarded in the common duct for a longer period than twenty-four
hours, and is of such a shape and size as to completely occlude the
duct, jaundice generally appears, the conjunctiva first showing a yellow
hue, which rapidly extends over the whole body. The color is more
or less pronounced in proportion to the extent and duration of the
obstruction to the flow of bile. The duration of the jaundice is usually
limited, being from two to six days, according to the number and size
of the stones.
Permanent occlusion of the duct, and consequent chronic icterus, is
of very rare occurrence.
The duration of an attack of hepatic colic is variable, depending
largely upon the size of the stones. An attack usually passes off in
three or four hours, although it may be prolonged to several days.
The pain sometimes ceases in consequence of the calculus falling back
into the gall-bladder after having passed into the opening of the cystic
duct. Occasionally, after passing from the cystic into the common
duct, the severity of the pain is sensibly lessened. As the stone finally
reaches the duodenal orifice, which is somewhat narrower than the
main canal, the pain becomes more intense, which increase quickly
subsides as the stone finally escapes into the duodenum, the patient
experiencing at once a feeling of marked relief. After the attack is
over, there is often for several days much soreness and tenderness.
As a rule, there is a succession of paroxysms of hepatic colic occur-
ring at variable intervals. They have been known to occur daily for
several weeks, but usually at intervals of weeks or months. In excep-
tional cases only a single attack has occurred, either because there has
been but a solitary calculus, or because on account of the dilatation of
the ducts by the passage of the first stone, the escape of the remainder
has been rendered easy and painless.
VOL. I.-56
882
.
A SYSTEM OF MEDICINE.
1
Successive attacks are accounted for by the fact that the stones
escape, one by one, at greater or less intervals of time, or by the sub-
sequent formation of fresh calculi.
For several days after an attack of hepatic colic the fæces, should be
carefully examined in order to ascertain if the stone has escaped from
the intestinal canal. If the stones are found in the fæces, their pres-
ence confirms the diagnosis, and also establishes the fact that they
have not slipped back from the cystic duct into the gall-bladder.
Not unfrequently several stones are found together in the stools, and
occasionally a large number of small ones.
Calculi usually escape from the intestinal canal without causing any
irritation or pain, unless they are unusually large, in which case they
may cause some flatulence and colicky pains, or a certain degree of
tenesmus as they emerge from the anus.
Diagnosis.-It is no easy matter to determine the presence of gall-
stones in the gall-bladder or biliary ducts. Calculi may remain for
an indefinite period, either in the bladder or ducts, without their pres-
ence being suspected or causing any morbid symptoms. If of small
size, they may escape unnoticed, particularly in the case of persons.
of advanced years, in whom there is diminished sensibility of the
visceral nerves. Stones situated in the gall-bladder oftener escape
detection than those in the ducts. Whatever morbid symptoms arise
from their presence are commonly attributed to functional derange-
ments of the abdominal viscera. In some cases cholelithiasis may be
pretty accurately determined by a crackling sound produced by ma-
nipulation in the region of the gall-bladder, or when a hard nodular
tumor is felt in the position of that organ.
Therefore, unless the patient is attacked with hepatic colic, the diag-
nosis of cholelithiasis is mainly conjectural.
On the contrary, the diagnosis of hepatic colic is usually readily
determined, especially is this the case when successive paroxysms.
occur. The diagnostic points are: The rapid invasion of the parox-
ysm; its occurrence two or three hours after a meal, or soon after
some violent muscular effort; the location of the pain to the right of
the epigastrium; the gastric derangement; the icteric appearance of
the conjunctiva and skin, the absence of fever, the retardation of the
pulse, and the sudden cessation of the pain. These symptoms, when
present, point conclusively to the nature of the disorder.
The affections for which hepatic colic may be mistaken are: gas-
tralgia, renal colic, acute indigestion, and intestinal colic. The inva-
sion of gastralgia is more gradual, and the pain is not as intense, and
has not the marked remissions of hepatic colic. The pain of gastralgia
begins soon after eating, that of hepatic colic two or three hours after
a meal. There is absence of tenderness on pressure in gastralgia,
whereas tenderness and soreness are conspicuous features of hepatic
DISEASES OF THE ORGANS OF DIGESTION.
883
colic. In protracted cases jaundice is a distinctive symptom, present
in hepatic colic, but wanting in gastralgia.
Renal colic may be recognized by the location of the pain in the
neighborhood of the ureters, by urinary derangements, retraction of
the testicles in the male, and presence of blood-disks in the urine.
Intestinal colic has more marked remissions, and the pain is at, or
around, the umbilicus. Lead colic is differentiated by retraction of
the abdominal wall towards the spine, and by other well-known signs
of lead-poisoning.
Neuralgia of the hepatic plexus of nerves closely simulates biliary
colic, and cannot be distinguished from it. Hepatalgia is, however,
of very rare occurrence, and many writers doubt its occurrence. In
doubtful cases, the group of symptoms attending each individual case,
or the finding of calculi in the fæces, can alone determine the diagnosis.
with any certainty.
The existence of biliary fistulæ can seldom be ascertained. The
passage of a large calculus from the intestines, or the impaction of one
in the intestinal canal, which is not preceded by an attack of hepatic
colic, is presumptive evidence of a fistulous opening.
Prognosis. The prognosis of hepatic colic is generally favorable.
Still, the opinion of the physician should be guarded, in view of the
many complications which may arise during the progress of a gall-
stone, from the beginning of its advance until its final escape from the
body. The accidents which may occur are: impaction of the stone
in the cystic or common duct, with resultant inflammation and ulcer-
ation, chronic icterus, rupture of the gall-bladder or ducts, impaction
in the intestines with occlusion, perforation of various organs, peri-
tonitis, etc. As regards the termination of cholelithiasis, the prognosis
should be still more guarded. Although in a certain proportion of
cases expulsion of the calculi is apparently followed by complete
relief, yet the predisposition to their formation continues, and attacks
of hepatic colic may recur in consequence of fresh formations, even
after the lapse of many years.
Treatment.-Treatment may be considered under two heads,
namely: first, arrest of the formation of stones and solution of cal-
culi already formed; secondly, treatment of hepatic colic.
As hepatic colic is, in the majority of cases, the initial symptom
which directs the attention of the patient and physician to the exist
ence of calculi in the gall-bladder and biliary ducts, it will be proper
to consider its treatment prior to that of cholelithiasis.
It is seldom that specific medication will be of any avail. The pain
and other symptoms are due to mechanical rather than to pathological
conditions, and the chief indication is to relieve the intense suffering
of the patient with the most effective means at our command.
A hot bath will often be of marked benefit, or if the patient is too
884
A SYSTEM OF MEDICINE.
restless to tolerate the bath, hot fomentations may be substituted
for it.
The remedies which are chiefly indicated are: Nux vomica, Atropiæ
sulphas, and Chelidonium.
Nux vomica relieves the pain by its action on the contracting fibres
of the ducts, thus facilitating the passage of the stone. It acts better
in the low potencies.
Hempel and Arndt (Materia Medica and Therapeutics, vol. ii., p. 486)
say of Nux in hepatic colic: "Nux will be found eminently useful in
hepatic colic, a colic characterized by the sudden invasion of the most.
excruciating pain in the epigastrium and right hypochondrium, nau-
sea and vomiting, spasmodic contractions of the abdominal muscles,
coldness of the extremities, profuse cold perspiration." It may be
necessary to give large doses in this affection; if the attenuations fail
to relieve, I should not hesitate to give the strong tincture in five-drop
doses, or the pulverized Nux in half-grain doses, repeating every half
hour, until some three or four doses had been given.
Belladonna, or its alkaloid, has proved serviceable in mild cases in
which the paroxysms of pain are not very intense.
A case has been recently reported to the writer as cured with Cheli-
donium. The patient, a woman, thirty years of age, had suffered for
several years with repeated fits of hepatic colic. Under the continued
use of Chelidonium the attacks became less and less frequent, and
finally ceased altogether, the patient at this date having been well for
three months.
Cinchona, Podophyllum, Card. mar., Cheonanthus, Colocynth., Lauroce-
rasus, Berberis, Lycopodium have in their pathogeneses some of the
symptoms characteristic of hepatic colic, and may be exhibited with
benefit.
As before remarked, the agonizing pain of colic is in consequence
of mechanical distension of the ducts and resulting laceration as
the concretion is forced along its narrow channel; therefore I am con-
vinced of the expediency, and even necessity, for the administration
of anodynes and anæsthetics in this most distressing affection, not
only to relieve the intense pain, but to avert the exhaustion and pros-
tration consequent upon so much suffering. It is advisable to admin-
ister the morphine hypodermically. As the system in this disease is
tolerant of the drug, one-sixth to one-fourth of a grain may be injected
in the arm once in two hours, until the pain is relieved. If adminis-
tered internally, it is liable to be rejected by vomiting. In very severe
cases, or in cases in which morphine is contraindicated, inhalation of
choloroform may be given with all the proper precautions needful.
It is not necessary to produce complete anæsthesia, but only to give
enough to allay the pain.
Having brought the patient successfully through one or more attacks
DISEASES OF THE ORGANS OF DIGESTION.
885
of hepatic colic, the treatment should, in the second place, be directed
to the prevention of future attacks, either by preventing the formation
of new concretions, or by promoting the solution of those already
formed. First in importance and efficiency are hygienic measures.
Indolent and sedentary habits, luxurious living, and over-indulgence
in the use of distilled and malt liquors, favor the formation of gall-
stones. It is, therefore, of the highest importance that the habits of
the patient should, in such respects, undergo a radical change.
Sleeping in a well-ventilated room, early rising, moderate and reg-
ular exercise in the open air, a diet so regulated as to improve diges-
tion and assimilation, and to promote normal alvine evacuations, and
moderation in the use of vinous and malt liquors are essential adju-
vants in the treatment of cholelithiasis.
The principal remedies for this affection are Berberis, Chelidonium,
Calcarea carb., Cinchona, Lycopodium, Sulphur, Terebinthina.
The testimony to the efficacy of these remedies rests on alleged
clinical experience. It is impossible to give definite indications for
their administration for very obvious reasons. Chloroform, ether,
olive oil, alkaline mineral waters, are all believed to possess the power
to dissolve biliary calculi, or to arrest the process of their formation.
It is undoubtedly true that a course of certain alkaline waters, notably
those of Ems, Vichy, and Carlsbad in Europe, and some of not so well
established a reputation in the United States, are followed by immu-
nity of greater or less duration from attacks of hepatic colic. Chloro-
form and olive oil are supposed to act as solvents of gall-stones, but it
is very doubtful if they have any such property.
If a large stone is impacted in the intestines, producing symptoms
of intestinal obstruction, the usual treatment proper in such cases
should be followed. As a last resort, the abdomen should be opened,
and, if possible, the calculus, by gentle manipulation, be passed along
the intestines; if this fails, it should be removed by an incision.
ACUTE HEPATITIS.
Synonyms. Local parenchymatous hepatitis, Suppurative hep-
atitis, Suppurative inflammation of the liver, Abscess of the liver.
Definition. An inflammation of the liver, either diffuse or cir-
cumscribed, ending in resolution or in suppuration. That variety
which is diffuse and ends by resolution is almost never seen outside
of hot countries, is, at best, little more than a tradition in medicine, is
of no practical interest, and deserves only slight consideration. The
circumscribed variety results almost uniformly in hepatic abscess, is
usually simple, though sometimes multiple, is occasionally met in
temperate latitudes, and possesses quite an interest. It attacks those
886
A SYSTEM OF MEDICINE.
in the prime of life, is often coincident, if not interdependent, with
dysentery, and has a duration so variable that the number of days
which measures one case may be the number of months which marks
the continuance of another. Taking no account of the multiple ab-
scesses of portal phlebitis, Murchison has remarked the fact that he-
patic abscess may be the result of pyæmia. In this case it is not the
disease, but a symptom of the disease; yet the local pathological con-
dition is the same.
Etiology. Let solar heat come beating downward in vertical rays
upon an atmosphere saturated with malarial vapor, put into this poi-
soned air and underneath this blistering sun a man of intemperate
habits, and you have done all that science can do to produce an in-
flammation of the liver with a resultant abscess whose overflow shall
be measured by pints. Heat is a prime requisite. Other things being
equal, the hotter the climate, the more hepatic abscesses. Those other
conditions are malaria and liquor-drinking. Heat and malaria are.
the two causes specially wrapped up in each other; heat without
malaria is robbed of half its terrors. If two climates be taken for ob-
servation, both of high temperature yet differing decidedly in the de-
gree of heat, it will be found that the less torrid is the more fruitful
in inflamed livers if it be steeped in malaria, while the hotter region
is free from this poison. So noticeable is this that the causal relation
of heat has, at times, been denied, although it would seem impossible
that a comprehensive view of the climatic and geographical home of
inflammatory disorders of the liver could leave a doubt in any mind.
Even those who urge that a cold north wind striking persons coming.
out of heated ballrooms in Calcutta is often as 66 a dart to strike
through the liver," suggest as prerequisite a cachexia induced by
life in the tropics. Again, the comparative rarity of hepatic abscess
in our own latitude, although the malarial taint abounds, emphasizes
the importance of climatic heat as a cause of this disorder. Take it
all in all, a high temperature is unquestionably the foremost of all the
causes which may be enumerated.
Malaria has already received incidental mention as a cause of he-
patic abscess. Such mention leaves upon the mind a very just im-
pression as to the estimate which may properly be placed upon its
influence as a factor in the production of this disorder. It is signifi-
cant, yet its significance is mainly incidental to the existence of other
influences. Though there be not enough malarial poison in the system.
to produce the characteristic pyrexia, still, it may be sufficient to so
oppose and clog the hepatic life as to make it the ready prey of an
influence which might not otherwise eventuate in an inflammation.
Perhaps its proper rank could not be better expressed than by denomi-
nating it a predisposing cause.
Intemperance occupies much the same plane as malaria, possibly
DISEASES OF THE ORGANS OF DIGESTION.
887
surpassing miasmatic conditions in its power for evil. Waring's elab-
orate statistics show, among other things, that in forty cases of hepatic
abscess, sixty-seven and one-half per cent occurred among those ad-
dicted to the use of alcoholic liquors. It may well be believed that a
habit which so notoriously affects the structure of the gland as to give
cirrhosis the popular name of " gin-drinker's liver," may be an effec-
tive agent in imposing upon its substance an inflammation which
finds no halting place short of suppuration. Maclean encountered
only one case resulting from direct violence, and that was in the person
of a drinking soldier who, while intoxicated, was thrown from a run-
away horse against a gate-post. It is fair to suppose that the alcoholic
cachexia was, in this instance, responsible for the enormous and fatal
abscess which followed; for blows upon the right hypochondrium
should tend to produce peritonitis rather than hepatitis. The use of
liquor is a constant menace to the soundness of the liver, and may, at
any time, render efficient for destruction adverse influences which had
otherwise been successfully counteracted by the conservative forces of
nature.
A large share of the discussion which has been had respecting the
causation of hepatitis has gathered around the question whether any
causal relation exists between dysentery and hepatic abscess. That
suppurative inflammation of the liver is often attended by a precedent
or coincident dysentery or intestinal ulceration is a matter of frequent
observation; but that the two disorders hold the relation to each other
of cause and effect is not so clear. Eminent authorities in this depart-
ment differ in their conclusions. Budd maintains that the decom-
posing products of ulcerations occurring almost anywhere throughout
the digestive tract furnish the poison which is at the bottom of the
mischief in the liver, access to the gland being obtained through the
portal vein. Moxon went so far in contending that dysenteric, or other
intestinal, ulcerations were the primary, and hepatic abscess the sec-
ondary, lesion that he considered "primary abscess of the liver at least
as doubtful as primary suppuration of the brain!" On the other
hand, such men as Frerichs, Morehead, and Murchison believe the
connection to be only apparent and purely incidental, and have the
weight of statistical evidence in their favor. Waring states that “out
of 2758 cases of dysentery treated in the Madras Presidency, abscess
of the liver occurred 68 times." In his collected fatal cases of inflam-
mation of the liver, 300 in number, it was "the primary affection in
131, or 43 per cent., while only 82, or 27 per cent., were admissions
from dysentery." In our own climate dysentery is of frequent occur-
rence, the familiar acquaintance of every physician; yet nothing is
further from our thought than any apprehension that these cases may
end in hepatitis. As both diseases are essentially heat-disorders, and
as in this latitude we have the dysentery alone, while in tropical re-
888
A SYSTEM OF MEDICINE.
gions they have, in numerous cases, the dysentery plus the hepatic
derangement, it may not be amiss to consider both of these maladies
as essential and practical manifestations of the destructive influence
of high temperature. Under this assumption dysentery becomes the
expression of the lesser degree of heat, and, under favorable conditions,
consecutive dysentery and hepatitis the expression of the greater de-
gree. This view assigns both to an identical cause of varying intensity,
and recognizes a connection between the two which cannot be ignored,
while repudiating the supposition of cause and effect, which is hardly
tenable.
Besides the generic causes already considered, cases are on record
the result of special circumstances. Thus in one instance the post-
mortem examination of a consumptive revealed an abscess in the liver
containing a needle two and one-half inches in length, the discharge
making its way into the duodenum without exciting suspicion of he-
patic trouble. Penetration by lumbricoid worms and impacted gall-
stone's have also furnished nuclei for suppuration.
It is not incredible that failure to recognize the lesion has shortened
our knowledge of the list of causes which produce this disease of the
liver. In 1878 Hammond put himself on record as having found that
in certain cases of gastric derangement, of cerebral hyperæmia, of in-
somnia, and of mental depression, there is a coexistent abscess of the
liver. This fact was not determined by the ordinary symptoms, which
were wanting, but by the free use of the aspirator. Out of twenty-six
of these exploratory punctures, the needle being thrust through one of
the two intercostal spaces between the eighth and tenth ribs into the
right lobe, fifteen determined the presence of an abscess, and evacuated
the pus. In the current edition of his work on the Nervous System he
says that "since the publication of the original paper on the subject
(in the St. Louis Clinical Record) other similar cases have come under my
notice." The researches of the late J. Marion Sims led him to corroborate
the statements of Hammond. This astonishing disclosure claims our
very thoughtful consideration, for when a man has actually sucked pus
through the needle of his aspirator it will hardly do to dismiss this
fact with a discussion of the possibilities of mistake, and a suggestion
that no pus was really obtained; that would be carrying scientific
skepticism to an unscientific extreme. Knowledge of the fact that
hepatic abscess may be so insidious in its development as to call no
attention to the liver, and that it has been found coupled with remote
and seemingly heterogeneous disorders, may be helpful in obscure
conditions, possessing, as we do, a means of actual exploration which
is harmless and safe.
Pathology. Suppurative inflammation of the liver is always.
limited to one or several isolated patches; and with the exception of
congestive turgor of the contiguous texture, the remaining portion of
DISEASES OF THE ORGANS OF DIGESTION.
889
*
the gland is rarely implicated. We do not often see the pathological
changes which characterize the commencing stage, as suppuration is
established before opportunities for investigation are offered. The
disease is supposed, however, to commence with active hyperæmia,
followed by effusion of lymph and degeneration of the hepatic cells,
causing the affected part to become swollen or prominent, pale, yel-
lowish, and softened; the suppuration begins in points in the centre
of the lobules, which gradually coalesce, forming abscesses of various
sizes. Sometimes the tissue surrounding the abscess is of a dark color
and indurated; in others, the dark color gradually fades into a pale
yellow, and sometimes the boundary is sharply defined. In recent
abscesses the cavity is found filled with a pale yellow pus, and the
walls consist of softened hepatic tissue, which hangs in threads into
the interior. They vary in size from a pea to a hen's egg, or may at-
tain much larger dimensions. Flint reports a case where five and a
half quarts were at once evacuated by an opening made through the
thoracic walls. He also mentions a case in which an abscess was
found to contain, after death, eighteen pints of pus, the entire organ,
except the left lobe, being transformed into a mere sac. At first the
abscess usually assumes a rounded form, but if it becomes incorporated
with other cavities in the immediate neighborhood, it becomes irregu-
lar in outline, the walls bulging in a sinuous manner, and traversed
by cord-like processes or bridges of hepatic tissue. The walls at first
consist of the hepatic tissue, but after a time a cyst is formed which
increases in thickness and firmness with age. Sometimes the walls
become gangrenous. If absorption occurs before the abscess becomes
encysted, the walls of the abscess approximate, unite, and ultimately
nothing remains but a linear cicatrix. It frequently happens that no
defined boundary is formed, and the inflammatory process continues
to extend, forming an enormous purulent collection, until perforation
occurs and the pus finds an outlet. The discharge rarely takes place.
into the peritoneal cavity, producing a fatal peritonitis, but in a large
proportion of cases the evacuation is through the thoracic or abdom-
inal walls. Sometimes the pus dissects downward along the spine,
discharging in the inguinal region, or by the sacrum posteriorly, or it
ulcerates through into the stomach, duodenum, or colon, or makes its
way upward, perforates the diaphragm, the lungs, and is discharged
through the bronchi. In rare cases the abscess has found its way
through the central portion of the diaphragm into the pericardium, or
has discharged into the portal vein or inferior vena cava.
Hepatic abscesses are sometimes superficial, but more often are deep-
seated, and most frequently occur in the posterior portion of the right
lobe. The number of abscesses present at the same time depends
greatly upon the cause; usually there are from one to three, rarely
* Flint's Practice of Medicine, p. 550.
890
A SYSTEM OF MEDICINE.
more, except when developed in consequence of pyæmia, when the
abscesses may occur in larger numbers. The purulent matter con-
tained in these abscesses may not differ in its characters from ordinary
pus, but frequently it contains more or less of the remains of the dis-
integrated hepatic tissues, and they sometimes contain bile. The
hepatic vessels are rarely involved in the suppuration, but it is quite
near them, they are liable to become inflamed, and their lining mem-
brane becomes rough and covered with fibrinous deposits which
fill up their calibre more or less completely. Anatomical lesions of
other organs sometimes occur; especially is the gastro-intestinal tract
liable to be implicated, its mucous lining being the seat of exudation-
processes and ulceration. This is especially the case when the disease.
occurs in tropical climates.
Symptomatology.-Taking into account the active life of the
liver, its double circulation and double function, the tolerance of in-
flammation and abscess which it displays is little short of marvelous.
That a gland of such size, and discharging such important offices,
should make so little complaint of invasion is not what a knowledge.
of physiology alone would lead one to anticipate. So quietly does it
accept the intrusion of the inflammatory process that the symptoms
are often obscure, and even the existence of any trouble, if we receive
the testimony of the aspirator, is, at times, overlooked. As usually set
down, the symptoms are a moderate degree of pain or uneasiness and
tenderness in the region of the liver and right shoulder, impaired appe-
tite and disturbed digestion, lassitude, and an aversion to both mental
and physical exercise. These symptoms alone are hardly sufficient to
give a clear conception of the disorder. But there is one little pecu-
liarity of the liver which, kept in mind, will do much to give meaning
to a train of symptoms otherwise meaningless and obscure. It is this:
While its investing membrane is endowed with perhaps a fair measure
of sensibility, its substance possesses very little. It might be put, with
considerable accuracy, in the language of physics, and affirmed that,
passing from the circumference of the liver to its centre, the sensibility
decreases as the square of the distance. If, then, we have an inflam-
mation deep in the substance of the gland, there will generally be fever
with the onset of the disorder, with little, if any, pain. But as the dis-
ease in its progress outward attacks the capsule, and a circumscribed
peritonitis is added, so that by means of adhesion a continuous, and
therefore safe, channel may be made for the exit of the pus into the
bronchial tubes, through the abdominal walls, or into the stomach,
there is a sudden accession of sharp, stabbing pain, marked chill,
active fever, and often cough. Thus the more acute symptoms are
likely to occur just before the termination of the disease, and not at
the outset. This is so contrary to our habit of thought that we must
needs have our wits about us if we do not care to mistake the end for
DISEASES OF THE ORGANS OF DIGESTION.
891
•
the beginning. In the beginning, the symptoms of inflammation
masked and obscure; in the ending, inflammatory symptoms well
marked and obvious-this is the typical hepatitis. So true is this
that diagnosis can press into its service nothing of a greater value than
these characteristics. It runs in exact parallel with them, its mere
suspicion of the liver amid the symptomatic obscurity of the first
stages being changed into reasonable certainty by the straightforward
behavior which marks the establishment of the last stage. Pus having
been formed, it is at first bounded by the substance of the liver. It
may seek immediate exit without waiting for the formation of any
limiting membrane, and the case will then move rapidly toward its
termination. At other times, a cyst-wall is thrown around the pocket
of pus, and there ensues a period of latency the length of which de-
pends upon the toughness of the cyst. In such cases the lesion may
be unsuspected, the liver working around this intruder and quietly ac-
complishing its functions without apparent disturbance. But sooner or
later the pus makes its way to the surface of the liver and is discharged.
It may remain an indefinite period of time, but discharge must take
place eventually, if life be not otherwise destroyed. The pus may
empty into the lung, the pericardium, the stomach, the duodenum, the
colon, the peritoneal cavity, or through the abdominal wall. If into
the pericardium or peritoneum, collapse and death are inevitable. If
into the stomach or duodenum, pronounced vomiting occurs; if into
the colon, diarrhoea may be expected, and the issue is not necessarily
fatal. Fortunately, the safest route is that oftenest taken, egress being
obtained through the abdominal wall, a point just below the ensiform
cartilage being the favorite spot. In this event we may look for the
symptoms of circumscribed peritonitis. Next in point of, safety is dis-
charge into the lung and removal by means of expectoration, a course
frequently adopted. Here the symptoms are those of pleuritis, and
cough is a necessary auxiliary.
Diagnosis. Reference has already been made to the fact that in
the beginning of the disorder the diagnosis can be little more than a
suspicion. In searching for the true condition of affairs it is first in
order to determine what organ is at fault. We must be content to
travel by the circuitous path of exclusion. We cannot come to our
decision in a single bound, as in the case of a pneumonia or a cholera
morbus. It is not impossible to mistake as between the stomach and
liver, lapses of the one having been charged to the other. First of all,
then, we must patiently and logically assure ourselves that the derange-
ment is hepatic. If suppuration has taken place, a fluctuating tumor
may present itself in the region of the liver. In the person of a child
eight years of age, presented at the Hospital Saint Jacques, Paris, the
tumor appeared on the anterior aspect of the gland, pushing the ribs
upward.
892
A SYSTEM OF MEDICINE.
Such a tumor must be distinguished from those which may appear
as the product of other causes. It must be distinguished from the
tumor which marks the evolution of an hydatid. The growth of the
latter is unaccompanied by systemic depression, neither is there local
pain and tenderness. It must be differentiated from an abscess of
the abdominal wall, which, by its hard, red, painful character and by
its history, is easily recognized. If a cancer, the familiar cachexia
and the nodulated "feel" would guide us, and the existence of a
gall-bladder distended by calculi or through obstruction of its outlet
would be determined by the history, the situation, the shape and the
mobility of the part.
Besides these means of differentiation between the various conditions
mentioned, we may avail ourselves of the important services of the
aspirator. It has been shown how the aspirator brought to light the
coexistence of hepatic abscess with disorders presumably disassociate.
When we are in doubt as to the nature of a tumor presenting in the
region of the liver, there is no reason why the needle of an aspirator
should not be employed to settle the question at once. Even when no
tumor is apparent, no valid objection can be urged against an explora-
tory puncture if the presence of pus is suspected, although the perfora-
tion of the liver seems, at first blush, a rather heroic measure. If the
search prove fruitless there is nothing to regret, since no harm results
if the instrument has been in intelligent hands.
Should the pus appear through a self-made opening in the abdomi-
nal wall, all questions of diagnosis would then be at an end. Should
it take one of the interior routes, the symptoms already detailed as at-
tending its emptying into these neighboring structures must dictate
the diagnosis. In those cases where the abscess discharges through
the lung, the previous good character of the lung and the large amount
of pus expectorated should preclude any liability to mistake the hepatic
lesion for a pulmonary disorder.
Prognosis. Hepatitis being' a disease which properly belongs to
the Torrid Zone, while enlightened Medicine is the child of temperate
climates, the two hardly made each other's acquaintance until the
British garrisoned India, and trained physicians were posted through-
out that hot peninsula. Their observations have been the chief con-
tributions to our knowledge of this disease. In their experience evacu-
ation of the abscess by means of trocar and canula, or other instruments,
was not followed by favorable results, and their verdict was in favor of
allowing the pus to find its way out unaided. Taking into account the
uncertainty of the pus, unassisted, selecting the least dangerous course,
and adding to this the contingencies which lie in the path of the most
favorable transit, it will be anticipated that the prognosis has been
universally regarded as doubtful and inauspicious. But with the in-
troduction of the aspirator a new factor entered into the question of
DISEASES OF THE ORGANS OF DIGESTION.
893
prognosis, increasing the probabilities of recovery. Eighty-one cases
treated by operative interference, without the aspirator, showed a
mortality of seventy-two per cent. Fourteen cases treated by aspira-
tion showed a mortality of forty-three per cent. But in noting this
difference it must be remembered that the eighty-one cases cited
would doubtless have exhibited a less mortality had no evacuation by
operation been attempted. Yet it is unquestionable that the introduc-
tion of the aspirator marked an era in the prognosis of hepatic abscess.
which cannot be ignored. Its skillful use does lessen the danger. After
all, one can but wonder at the number of recoveries which take place
under any and all methods of treatment. Not unreasonably it might
be supposed that an inflammation of an important abdominal viscus,
ending in suppuration, would be almost certain to terminate fatally.
But out of two hundred and three cases collected, irrespective of treat-
ment, forty-one recovered. The disease falls far short of being a hope-
less one, though there are no reliable data which will enable the physi-
cian to foretell the issue with even approximate accuracy.
Treatment. The long and animated discussions as to the value
of blood-letting and saturation with Mercury may safely be ignored.
Neither procedure is worthy of serious consideration. In the earlier
stages of the disease, when the diagnosis is uncertain, the expression
of the disorder through its subjective symptoms will yet give the
homœopathist a scientific basis on which to rest an intelligent treat-
ment. Any initial inflammatory symptoms will suggest a treatment
too familiar to need rehearsal here. Beyond this the remedies spe-
cially applicable are Bryonia, Phosphorus, and Silicea.
Bryonia will possibly do good in the incipient stage of the disease,
before suppuration has commenced. The symptoms preceding sup-
puration are included in the pathogenesis of Bryonia. There is pain
and sensitiveness in the right hypochondrium, pain and tension in
the right shoulder. Hughes has used this remedy, and holds that it is
demanded in those cases where the surface is the part most affected,
i. e., perihepatitis.
Clinical experience has demonstrated the utility of Phosphorus after
suppuration has been established. I cannot give any provings to show
its adaptability.
Silicea, in its provings, has swelling, inflammation and suppuration
of glands; abscesses, with tardy recovery. This would indicate its
use in protracted cases. In the case of a patient who died, life was
prolonged for eighteen months after the abscess was formed, and she
died finally of general anasarca. I did not see her until eight months
after the abscess opened.
It is not without interest, in connection with the widely divergent
views held by those of the old school who have encountered this
malady on its native heather, concerning the efficacy of mercury, to
}
894
A SYSTEM OF MEDICINE.
note that Hughes obtained pleasing response from the prescription of
Mercurius solubilis 3. Jahr seems to lay as much stress upon Bella-
donna and Mercurius as upon Bryonia. Other remedies which have.
received mention are: Chamomilla, Chelidonium, Hepar sulph., Kali
carbonicum, Lachesis, Lycopodium, Nux vomica, Pulsatilla, Sulphur.
So soon as the presence of pus may be reasonably suspected, it is
good practice to draw it off through the needle of an aspirator. If
the needle fails to find pus, no harm is done; on the contrary, positive
good seems to result to an extent quite unaccountable. All who have
placed on record their experience in those cases where abscesses have,
by this means, been actually found and emptied, are unanimous in
the assertion that the result is good, and only good. Many times re-
covery follows with great promptness. With no risk attending the
puncture, whether the diagnosis be correct or mistaken, the wound
being so slight as to leave no cicatrix which a post-mortem can dis-
cover, with prompt and positive convalescence often resulting, it would
seem that failure to call in, or, at least, consider, this method of active
interference, could hardly be justified. It is true that the instinctive
feeling is that such a proceeding must be risky. The first man who
tapped a dropsical abdomen must have held his breath. But careful
hands will inflict no damage though a slight mistake be made. In
attempting to reach an abscess of the liver, the gall-bladder has been
entered, but I cannot find that any untoward result followed. Even
the pericardium has, by design, been punctured without disaster. If
a rational conception of the exact amount of risk involved be once
compassed, patients will hardly be denied the benefit of this measure
for their relief merely because physicians have not the courage to
carry their convictions into practice.
ACUTE ATROPHY OF THE LIVER.
Synonyms. Hepatitis diffusa, Parenchymatosa; Yellow atrophy
of the liver.
Definition.-An acute disease of the liver, characterized by rapid
decrease of size and structural change, with jaundice. The disease is
accompanied by severe disorders of the nervous system.
History. The disease, under different appellations, has been rec-
ognized and described by some of its more marked symptoms, by
various writers, as far back as the time of Hippocrates. The peculiar
color of the liver was first pointed out by Valsalva.
Rokitansky, in 1842, was, however, the first observer who by a de-
scription of the clinical symptoms and by a subsequent autopsy gave
acute atrophy of the liver a well-defined place in nosology. During
the last forty years many writers, particularly in Germany, have
patiently and thoroughly studied the symptomatology, pathology, and
DISEASES OF THE ORGANS OF DIGESTION.
895
histology of this rare malady, and have furnished many valuable con-
tributions to the elucidation of the subject. Those more especially
worthy of mention are Klob, Klebs, Wunderlich, Opholzer, Frerichs,
and Liebermeister.
Etiology. The causes of acute atrophy of the liver are very ob-
scure. In a large proportion of cases it is impossible to assign any
definite cause. Age, sex, condition of life, antecedent disease of the
liver, mental emotions, venereal excesses, and acute infectious diseases
have been named as predisposing and exciting causes. As regards
the age at which the disease is most liable to make its appearance, it
has been ascertained that about three-fourths of all cases occur be-
tween the ages of sixteen and forty. Before and after this period of
life the number diminishes rapidly. Of 143 cases, nine occurred
during the first five years of life, but none between the ages of five
and nine years, while during the period between twenty and thirty
years of age there were no less than seventy cases.
The disease occurs more frequently in females than in males, the
proportion being as three of the former to two of the latter.
Of the women attacked, nearly one-half were pregnant. It would,
therefore, appear that pregnancy is one of the exciting causes of acute
atrophy, but the disease does not manifest itself in the earlier months
of gestation. Of eighty cases occurring during pregnancy, none were
observed during the first three months. Notwithstanding the fact that
a large proportion of cases occur during the pregnant state, yet the
disease is of very unfrequent occurrence in women in this condition.
Carl Braun observed it in but 1 out of 28,000 pregnancies.
The disease occasionally develops during the course of cirrhosis,
associated with long-continued obstruction of the hepatic ducts, and
also in fatty degeneration and other chronic diseases of the liver.
A certain proportion of cases of acute atrophy follow some intense
mental emotion, as inordinate anger, great fear, or long-continued
anxiety.
To venereal and vinous excesses other cases may be reasonably
attributed, but repeated experiments upon animals of acute alcoholic.
poisoning do not, with any certainty, develop appearances character-
istic of the malady.
According to Thierfelder (Ziemssen, Cyclopædia, vol. ix., p. 246),
the granular degeneration of the hepatic cells, which forms an altera-
tion uniformly present in the majority of acute infectious diseases,
may exceptionally attain so high a degree in some of these affections-
such as puerperal fever, recurrent fever, abdominal typhus-that an
acute wasting of the liver is thereby produced. Bohl observed in a
form of puerperal fever, described by him as pyæmia, associated with
peritonitis, parenchymatous degeneration of the liver in every stage,
even to a most typical picture of acute atrophy of the liver. Two
896
A SYSTEM OF MEDICINE.
cases of puerperal peritonitis are likewise described by Hugenberger, in -
which the liver presented all the characters of acute atrophy. In the
epidemic recurrent fever at St. Petersburg in 1864, Kaillner found in
several cases the liver of a consistence resembling perfectly that pre-
sented by the organ in acute atrophy. Similar lesions have been de-
scribed by Frerichs in sporadic cases of typhoid fever; also by Op-
holzer and Eppinger. Liebermeister observed the development of the
disease in a man, sixty-three years old, during the course of a catar-
rhal fever with ultimate croupous pneumonia.
Pathology. Acute atrophy of the liver offers many striking ana-
tomical characters, and is supposed to involve a peculiar morbid pro-
cess which is not fully understood. Most authorities consider that this
unknown morbid process excites an acute diffuse parenchymatous in-
flammation of the liver which results in the condition known as acute
yellow atrophy. The disease has also been attributed to obstruction.
of the smaller bile-ducts, or to excessive formation of bile within
them, whereby pressure is exercised on the surrounding structures.
The liver undergoes a rapid and notable reduction in size, the dimi-
nution amounting to a third or a half, or even two-thirds, of the orig-
inal size, the weight being proportionately lessened. This diminution
in size occurs in "every direction, but especially in the thickness of the
organ, which is sometimes reduced to an inch at its thickest, the gland
being flattened out. The capsule presents an opaque, puckered ap-
pearance; the parenchyma is flabby and shrivelled, so that it is un-
able to bear its own weight, and folds up, or collapses. The tissue is
soft, easily broken down, and is sometimes pulpy. The peritoneal
layer is roughened and wrinkled. The cut surface of the organ pre-
sents at those places where the disease has advanced farthest, and
these are usually in the left lobe, an ochre-yellow, or rhubarb-like
color; the blood vessels are here empty, and in most cases the outline
of the lobules is no longer visible. At other places where the morbid
process is at an earlier stage, some of the capillaries are filled with
blood, and occasionally there may be seen extravasations, or their
remains, in the form of crystals of hæmatoidine. Between the lobules,
which are encircled by the congested vessels, and separating them from
one another, a dirty grayish-yellow substance is deposited. At a later
period, the capillary congestion recedes, the size of the lobules dimin-
ishes, and their color becomes yellower, whilst the relative amount of
the intervening gray substance disappears at those places where the
atrophy of the gland is most apparent, and the organ assumes more
and more a uniform yellow tinge, from which the outlines of the lob-
ules by degrees completely disappear."* Microscopic examination
reveals fatty degeneration and destruction of the gland cells, until
ultimately nothing remains but a granular detritus, oil-globules, and
* Frerichs, Diseases of the Liver, William Wood & Co., 1879, vol. i., p. 158.
DISEASES OF THE ORGANS OF DIGESTION.
897
pigment. There is generally only a little gray mucus or a little un-
healthy bile in the gall-bladder and bile-ducts. Extravasations of
blood in the alimentary canal and other parts, with ecchymoses, are
not uncommon. The spleen is usually, but not invariably, increased
in size. The kidneys exhibit degeneration of, and deposits of pigment
in, the epithelium cells. Leucin and tyrosin are found in the blood,
as well as in the tissues of the liver, spleen, and kidneys. The mus-
cular tissue of the heart undergoes more or less fatty change, but this
alteration is found with many other acute diseases.
Symptomatology.-Gastric derangement and jaundice are, in a
majority of cases, the symptoms first observed. In some instances,
however, the premonitory symptoms are mild, and in no wise indicate
the gravity of the disease or the approach of danger. The patient is
affected with loss of appetite, feeling of languor and debility, pressure
and uneasiness at the epigastrium, furred tongue, nausea and vomiting.
There may be also slight fever. The bowels are either constipated or
loose.
In a few days jaundice, resembling in many respects catarrhal jaun-
dice, is superadded to these symptoms. The symptoms already de-
tailed constitute the first or prodromal stage, and usually are not suffi-
ciently severe to confine the patient to the bed or even to the house.
After a period of from two or three days to several weeks, the disease
passes somewhat suddenly into the second or nervous stage. The first
stage may, however, be protracted to a much longer period, or, on the
other hand, be limited to less than a single day.
Without much warning, severe disturbances of the brain appear.
The patient becomes restless, uneasy or delirious, finally passing suc-
cessively into a state of drowsiness, sopor, coma, or convulsions. Re-
peated vomitings and involuntary discharges of urine and fæces fre-
quently occur. The stools, which at the outset of the disease were
tinged with bile, become of a clay color. Cramps of the involuntary
muscles are occasionally observed.
Important changes in the blood often appear, manifested by vomit-
ing of grumous matter from the stomach, hæmorrhages from the in-
testines, vagina, and kidneys, extravasations of blood into the connec-
tive tissue, and ecchymosed spots.
In the second stage the fever, if there has been any, subsides. The
urine is diminished in quantity, becomes of a darker color, and con-
tains bile, tyrosine, and leucine.
Towards the last, the coma and insensibility become more profound,
the pulse becomes rapid, feeble, and irregular, symptoms of oedema of
the lungs or of collapse appear, and death ensues with indications of
profound prostration.
Physical Signs.-Occasionally, during the first stage, examina-
tion shows a rapid decrease in the area of dulness, indicating a dimi-
VOL. I.-57
898
A SYSTEM OF MEDICINE.
nution in the size of the liver, but atrophy usually begins with the
advent of the second stage. As a rule, however, the reduction in size
becomes appreciable only in the latter phases of the disease, usually
during the last three days of life. The diminution becomes first
apparent in the left lobe, the dull sound in the angle formed by the
angle of the ribs being replaced by tympanitic resonance. In the
right lobe the shrinking proceeds from below upwards, until finally
only a narrow strip of dulness is perceived between the lungs and the
intestines. The liver appears to be bent backwards, and the anterior
space to be filled by coils of intestines. The diminution in size is not
only evident by the decrease in the area of dulness, but the fingers
forced up under the ribs fail to detect the organ in its normal position.
In some cases acute atrophy of the liver is preceded by increase in
bulk. In one case the first examination showed a normal area of
dulness; two days later, there was increased area of dulness, and at
the end of two days more, it was less than normal. In other cases no
apparent decrease in size has been observed, either in consequence of
the rapid progress of the disease to a fatal termination, or because the
disappearance of the granular cells was accompanied by hyperplasia
of the intestinal tissue.
Sensitiveness in the region of the liver is, in the majority of cases,
perceived even when the patient is in a state of coma, as is evidenced
by a contraction of the facial muscles and by a shrinking from pres-
sure upon the organ.
It is doubtful whether the manifestations of pain are due to in-
creased sensitiveness of the liver or to hyperæsthesia of the skin, inas-
much as many patients shrink from pressure upon other parts of the
body. Pain is not by any means a constant symptom, being, accord-
ing to Frerichs, present in only three-fourths of the cases recorded by
him. By other observers its absence is expressly noted in a certain
proportion of cases.
Of the three most prominent characteristic symptoms of the disease,
namely: gastric derangement, icterus, and cerebral disorder, more par-
ticular mention will need be made.
Gastric Symptoms.-Impairment of appetite is the first and
most constant derangement. Vomiting occurs in the first stage in the
majority of cases, and nausea is usually present in the remainder.
In the second stage, and especially with the advent of the cerebral
manifestations, vomiting is a constant symptom. The ejected matter
is mixed with mucus, and not unfrequently it is tinged with bile. The
bowels, as a rule, are constipated, diarrhoea being of rare occurrence.
The stools at first contain bile, but in the second stage become clay-
colored. Occasionally they contain blood, more or less altered in
character.
Icterus. Jaundice may appear simultaneously with the gastric
DISEASES OF THE ORGANS OF DIGESTION.
899
symptoms, or after an interval of several days. In a few instances it
does not make its appearance until after the lapse of six or seven days.
At first the skin is not as dark as in obstructive or catarrhal jaundice,
but as the disease advances the color increases in intensity, and be-
comes of a deep yellow, saffron, or greenish tinge. The urine is scanty,
of a dark color, and shows the presence of bile under the usual tests.
In rare cases jaundice is absent. Bamberger reports a fatal case in
which no trace of jaundice was discovered during life, nor on the
cadaver, and yet the liver presented a well-marked example of atrophy,
with almost complete disintegration of the hepatic cells.
Cerebral Symptoms.-Coincident with the appearance of jaun-
dice, or soon after, disorders of the nervous system manifest themselves.
These do not follow a well-defined order, but vary widely in intensity
and variety of symptoms. Usually the patient complains of head-
ache, is irritable, moody, and restless. Less frequently there is abnor-
mal sensitiveness to light and noise. These lighter symptoms continue
for a few days, when severer manifestations appear.
When, however, the disease runs a very rapid course, the milder
nervous symptoms may be wanting, and active delirium, stupor, coma,
or convulsions appear without previous warning.
The delirium is commonly of an active, violent character, mani-
fested by screaming, throwing oneself about, excessive loquacity, inco-
herent talk, and efforts to escape. At times the delirium assumes the
form of mania. Delirium is not present in all cases, it being absent
in about one-fifth of the whole number. Unconsciousness, varying in
degree from somnolence to profound sopor and complete coma, is
present in nearly all cases. Convulsions generally occur in patients.
who have not passed the period of childhood; in adults they are ob-
served in nearly one-third of the cases. Muscular tremors and twitch-
ings of groups of muscles are occasionally seen; paralysis in some in-
stances occurs.
The nervous symptoms, as a rule, constantly augment in severity
until the end. The coma becomes more profound, the pupils are
widely dilated, the respiration becomes sighing, and finally stertorous,
and in some cases irregular and intermittent. As death approaches,
the number of respirations increases, and may rise to forty or fifty
per minute.
Duration. The duration of the disease varies considerably in dif-
ferent cases. In the milder cases the premonitory symptoms may last
from two or three days to several weeks. The second stage lasts from
one to ten days. Jaundice may appear in the first stage, or may even
precede the other manifestations. In some cases, characterized by a
sudden appearance of the severer symptoms, the attack often ends in
death in two or three days, or even sooner. From a table of 102 cases
900
A SYSTEM OF MEDICINE.
prepared by Thierfelder, it appears that the duration of the disease
ranges from two to thirty-two days.
Diagnosis.—At the outset of acute atrophy of the liver it is very
difficult, and in many cases impossible, to determine with any cer-
tainty the nature of the disease.
The gastric derangements which so frequently precede the advent of
the severer symptoms are not of a character to sufficiently indicate
the nature of the morbid changes which are going on in the liver. It
is not until icterus, conjoined with cerebral disorder, appears that the
true nature of the malady can be with any confidence determined.
Acute atrophy is liable to be at first confounded with simple jaundice.
In the second stage the diagnosis is more readily made. The jaundice,
the cerebral symptoms, the hæmorrhages, the presence of tyrosine and
leucine in the urine, the subsidence of the fever, and the rapid diminu-
tion in the size of the liver, evidenced by the decrease of the area of
hepatic dulness, constitute a train of symptoms which do not belong
to any other disease.
Acute phosphorus poisoning can, with extreme difficulty, be distin-
guished during life from acute atrophy of the liver. There is a striking
similarity in the clinical symptoms, and care should be taken to guard
against an incorrect diagnosis by thorough investigation. Thierfelder
considers that if decrease in size of the liver can be distinguished before
the expiration of the first week, phosphorus may, with certainty, be
eliminated from the possible causes of the disease.
Prognosis. The prognosis is exceedingly grave. Very few recover
from a well-marked case of acute atrophy. A few alleged cures are
recorded, but it is doubtful if the diagnosis in such cases was correct.
As before remarked, the duration of the first stages varies considerably,
but after the invasion of the second stage death occurs in the large
majority of cases in from one to three days. Out of 118 cases only
three survived more than nine days.
The conclusion of all observers of this most formidable disease is
that it is almost absolutely fatal.
Treatment.-The only remedy which promises any favorable re-
sult is Phosphorus. Inasmuch as poisoning by Phosphorus develops
a train of symptoms which can, with difficulty, be distinguished from
those of acute atrophy, the drug is certainly pathogenetic to the dis-
ease. I cannot ascertain that any cures are recorded from the admin-
istration of Phosphorus, but it is worthy of a thorough trial.
Allen, in his article on Phosphorus (Encyclopædia of Pure Materia
Medica), collates the symptoms from 232 cases of poisoning and prov-
ings. I find, among others, the following group of symptoms similar
to those observed in acute atrophy.
Mind.—Violent delirium, at first alternating with periods of con-
sciousnesss; sudden delirium, followed by a comatose state; violent
DISEASES OF THE ORGANS OF DIGESTION.
901
delirium (with intense icteric color of the skin); delirium, with con-
stant efforts to escape; delirium, with symptoms of paralysis; loqua-
cious delirium, anxiety, and restlessness; stupor, succeeded by low
muttering lethargy; complete apathy; pupils insensible to light; pulse
small, thready; stertorous respiration; great prostration, followed by
death.
Gastric.-Nausea, vomiting; vomiting of matter resembling coffee-
grounds; vomiting of ejecta, at first yellowish, afterwards blackish-
brown; hæmatemesis; atrophy of the liver, associated with meteoris-
mus, thin colorless stools, furious delirium, much jaundice, followed
by sopor, rapid pulse, contracted pupils, and death; constipation, fol-
lowed by diarrhoea; hæmorrhage from the bowels; hæmaturia; hæm-
orrhage from the vagina.
Skin.-Jaundice; skin deeply orange-yellow; petechial spots in the
skin; ecchymosed spots on the skin; spots similar to purpura hæmor-
rhagica at the base of the neck, the shoulders, and back of the hands.
For a disease which has so uniformly proved fatal, it is difficult to
suggest a line of treatment which will be at all satisfactory to the
physician, or which will afford a hope of recovery. The remedies
other than Phosphorus, which merit careful consideration, are Arseni-
cum, Belladonna, Hyoscyamus, Hamamelis, and Cinchona.
CHRONIC ATROPHY OF THE LIVER.
Synonyms.-Cirrhosis, Hobnailed liver, Granular liver, Intersti-
tial inflammation of the liver.
Definition.-Chronic atrophy of the liver is a chronic disease of
very slow progress, in which the organ becomes indurated and more
or less diminished in size. It generally begins with gastric derange-
ment, but sometimes with hepatic enlargements, followed by atrophy.
The progress of the disease is attended with considerable diminution
in size of the liver, ascites, anæmia, and progressive debility.
Etiology. The immoderate use of intoxicating drinks is the most
frequent cause. The more powerful stimulants, as brandy, gin, and
whiskey, are much more potent factors in producing the malady than
vinous and malt liquors, though the excessive and continued use of
the latter has been known to produce the same effect as the stronger
liquors. So many cases of cirrhosis are the result of excessive con-
sumption of spirits that the disease is known in England and Ger-
many by the name of "gin-drinker's liver." Budd attributes the
frequency of cirrhosis in India to the immoderate use of curry and
other stimulating condiments. Frerichs says the disease is sometimes
induced by excessive use of spices and strong coffee.
Other causes are syphilis and malarial fevers.
Frerichs cites six
902
A SYSTEM OF MEDICINE.
cases of cirrhosis which were undoubtedly attributable to syphilitic
poisoning.
In localities where malarial fevers are severe and of frequent occur-
rence, the malarial cachexia constitutes an important ætiological factor
in the development of cirrhosis. In the tropical regions of North
America, and in parts of Europe where malarial fevers abound, the
structural changes in the liver which occur as a consequence of mala-
rial influence, result in a variety of atrophy of the liver closely re-
sembling cirrhosis.
Trousseau holds to the opinion that some cases of the disease are
due to passive hyperæmia of the liver depending on a cardiac affection.
This author (vide Trousseau's Clinical Medicine, vol. ii., p. 757) says
most of the immediate causes of cirrhosis may be grouped under
three heads, viz.: First, chronic hyperæmia of a passive character, de-
pending on heart disease or paludal cachexia; second, chronic hyper-
æmia of an active character depending on alcoholic toxæmia; and
third, chronic active hyperæmia depending on syphilis.
Age and sex constitute predisposing causes. Cirrhosis is generally
a disease of middle life. Of 165 cases, 108 were between the ages of
thirty and sixty years. In early childhood and old age very few cases.
occur. One case is reported at the age of eight years, one at nine, one
at ten, two at eleven, one at thirteen, and one at fifteen. Five of these
are attributed to the use of alcoholic stimulants. Men are more sub-
ject to the disease than women, the proportion being as five to two.
Of 147 cases, 107 were men and 41 women. This fact is to be ac-
counted for by the greater prevalence of drunkenness among the male.
sex rather than to any special predisposition.
Pathology. Several distinct morbid conditions of the liver have.
been included under the head of chronic atrophy of the liver, or cir-
rhosis, which have totally different modes of origin. The genuine
disease is usually considered as resulting from a chronic interstitial
inflammation, extending into the minutest portal canals, and leading
to proliferation of cellular tissue in the lobules; or, as some patholo-
gists describe, to the formation of an exudation which undergoes.
organization, and then contracts, with consequent pressure upon, and
obliteration of, the vessels, and atrophy of the secreting elements.
This is the pathological view generally held at the present time. Ac-
cording to Dr. Goodeve,* it has yet to be determined whether cirrhosis.
is the result of a primary degenerative process, or of inflammatory
exudation or congestion, but he thinks it probable that it may orig-
inate in either of these processes. The commencement of cirrhotic
disease is marked by an increase in size, the organ being hyperæmic.
At this time the granular appearance is absent, or but slightly marked,
while the entire organ is congested, and is described as being occupied
* Reynolds, System of Medicine, vol. iii., p. 377.
DISEASES OF THE ORGANS OF DIGESTION.
903
by a succulent, vascular, grayish material, consisting of young con-
nective-tissue elements, containing spindle-shaped cells. The color of
the organ at this period is a brownish-red, or it may be greenish by
staining of the bile pigment; or the deposition of fat may give it a
pallid appearance. The liver now gradually becomes contracted,
atrophied, and diminished in weight, being sometimes reduced to two-
thirds or one-half of the normal size. This diminution occurs espe-
cially in the left lobe, which, not unfrequently, is shrivelled up into a
small membranous-like appendage, with a soft flabby rim of connec-
tive tissue at the margins of the organ. The surface is pale, and is
covered more or less with semi-globular knobs or prominences, like
hobnails, sometimes of a uniform, at other times of an unequal, size
and form; hence comes the name of granular or hobnailed liver.
The serous capsule is thickened, opaque, and of a grayish-white color,
especially in the depressions between the granulations. Numerous
bands of connective tissue pass from it to neighboring organs, such as
the diaphragm, colon, and stomach. The substance of the cirrhotic
liver is very hard and cartilaginous. On section there is often ast
much resistance as on cutting into scirrhus, and on the cut surface we
find the same granulations as on the surface of the liver. They are
imbedded in a dirty-white, dense, non-vascular tissue. At some places
the parenchyma has entirely disappeared, and the dense tissue alone
remains. On microscopic examination in this stage we no longer find
the first elements of connective tissue, this being fully formed, and
inclosed in concentric layers or groups of liver cells, the latter consti-
tuting the substance of the granulations. These remain intact for a
long period, but ultimately become filled with fat and various sorts of
pigment. The abnormal pigmentation is due to the compression of
the terminal ducts and stasis of the bile. The whole tissue which the
microscope reveals is generally supposed to be made up of fully devel-
oped fibrous tissue, or of young connective-tissue elements in process
of development, and chiefly resulting from proliferation. It has some-
times been described as consisting in some instances of the remains
of the vessels, ducts, and other tissues which have not undergone
destruction. According to Frerichs* the vascular system of the liver
undergoes important changes. Many of the smaller branches of the
portal vein are compressed or obliterated, and its capillaries are de-
stroyed. The vessels lose their rounded form, and become angular
and bulging. The main trunk of the portal vein, and the larger
branches, are often dilated, and may be occupied by thrombi. The
hepatic artery also becomes dilated, and supplies the newly formed
vessels of the recently developed connective tissue, and black pigment
is frequently found in its branches. The chief divisions of the hepatic
vein remain unchanged; but their obliteration may take place by in-
* Op. cit., p. 73.
904
A SYSTEM OF MEDICINE.
flammation, from the capsule of the liver, being propagated to the
walls of the vessels, when the capillary tributaries are gradually oblit-
erated, and their communication with the portal capillaries is inter-
rupted. The remaining capillaries are commonly in a state of fatty
degeneration.
The origin of the bile-ducts at the periphery of the lobule is de-
stroyed by the pressure of the new connective tissue, and there is apt
to be catarrhal tumefaction of the mucous membrane of the larger
branches. These various changes occurring in the liver may give rise
to a long train of secondary functional derangements of a serious char-
acter. "(1) Functional derangements of the chylopoietic viscera, arising
from the interruption to the circulation from the portal into the hepatic
veins, causing stasis in the whole range of the portal system; (2) Im-
pairment passing on to complete suspension of the hepatic functions,
-the formation of bile, glycogen and urea; (3) Impairment of those
functions which, in addition to the secretion of bile, the hepatic paren-
chyma perform in the metamorphosis of matter and in the elaboration
of blood."*
Symptomatology.-The physician seldom has the opportunity of
observing a case of chronic atrophy of the liver in the incipient stage.
Usually when the patient seeks medical advice, the disease has made
considerable progress, and he seeks relief from the ascites or one of the
numerous complications which occur during the course of the malady.
It is only in exceptional cases that the first development of the disease
is attended with much suffering.
If cirrhosis commences with symptoms of acute inflammation, there
is at the outset decided pain and tenderness in the region of the liver,
aggravated by deep inspiration, and severe in proportion as the capsule
and upper portion of the liver is involved. In these cases, the liver is
generally increased in size at first, so as at times to show considerable
enlargement, extending even to the umbilicus. The increase in size
is due to inflammation and hyperplasia of the connective tissue, and
gradually disappears with the subsequent shrinking of this structure,
and degeneration and atrophy of the hepatic lobules.
In the majority of cases the disease commences without any signs
of inflammatory action. The symptoms in the early stages are ob-
scure, and mainly referable to disorders of the digestive organs. The
appetite is poor or variable; digestion is imperfect, and is attended.
with eructations, nausea, flatulence, and feelings of oppression at the
epigastrium. The bowels are irregular, sometimes constipated, at
other times loose. The stools are often mixed or coated with trans-
parent mucus. Owing to variations in the quantity of bile secreted by
the liver, the stools are at one time dark, at another clay-colored.
Frerichs observed that the stools were not unfrequently parti-colored
* Frerichs, op. cit., p. 74.
DISEASES OF THE ORGANS OF DIGESTION.
905
from the admixture of bile in the contents of one portion of the in-
testinal tract and its absence in another part. These symptoms may
continue for months without any material change in the condition of
the patient, except increasing debility, emaciation, and anæmia. To-
wards the close of life diarrhoea and tympanitic distension of the in-
testines are almost invariably present. The stools then become pale
and watery.
With the progress of the disease, attended by increasing atrophy of
the liver and consequent compression and obliteration of the hepatic
vessels, effusion of serum into the abdominal cavity takes place. The
ascites is attended, or soon followed, by distension of the superficial
veins of the abdomen. Thierfelder accounts for the dilatation of the
superficial abdominal veins by the pressure of the effused fluid upon
the vena cava, thereby obstructing the blood current and impeding
the outflow from the veins of the abdominal integuments.
Ascites is usually developed slowly, increasing in proportion to the
progressive atrophy of the liver. In some cases there is a decrease in
the quantity of the ascitic fluid, or even a complete arrest of the
effusion, in consequence of an enlargement of the collateral blood
channels.
The effused fluid is generally clear and of a straw color, but some-
times is brown from the presence of bile pigment, or reddish in con-
sequence of extravasated blood-cells. The fluid contains from one and
a half to three per cent. of solid matters, of which about one-half is
albumen.
Edema of the lower extremities commonly follows within a variable
period after the appearance of ascites. The pressure of the fluid in
the abdominal cavity upon the iliac veins impedes the return of the
venous blood and leads to effusion of serum into the connective tis-
sue. The dema eventually affects the scrotum, labia, loins, and
anterior abdominal walls. The upper part of the body is rarely im-
plicated.
There are, however, many exceptions to the rule. Edema may ap-
pear in the lower extremities and in the whole lower half of the body
before the mechanical conditions producing intra-abdominal pressure
are produced. It may appear in the first period of the affection when
its course is subacute, and marked abdominal symptoms are presented,
as hepatic and intestinal pain, dyspepsia, vomiting, albuminuria, etc.
Edema may also be slow in making its appearance in cirrhosis, whether
before the symptoms of the hepatic affection are well defined or when
it has already arrived at an advanced stage.
According to Dr. Giovanni, the principal course of the oedema of the
lower part of the body is a special lesion of the inferior vena cava, and
not pressure upon the intra-abdominal veins. The inferior vena cava
in these cases is always found in a very marked state of hydræmia and
906
A SYSTEM OF MEDICINE.
dilatation, with well-defined lesions of peri- and endo-phlebitis, and
with considerable thickening of the vein walls. When, on the contrary,
no œdema appears during life, the vena cava is found in a perfectly
normal state.
Vomiting of blood and, less frequently, hæmorrhage from the bowels.
occur when the quantity of ascitic fluid greatly distends the abdomen.
Occasionally, hæmatemesis takes place prior to the appearance of
ascites. Rollet observed (Ziemssen's Cyclopædia, vol. 9, page 194)
hæmatemeses recur during a period of two years, almost regularly at
intervals of from two to five weeks, after which the ascites, that had in
the mean time re-accumulated in each instance, abated.
Hæmorrhages from other parts of the mucous surfaces are sometimes
observed.
Dyspnoea is generally an accompaniment of great distension of the
abdomen, the diaphragm being impeded in its action by the pressure
from below.
In the later stages of cirrhosis, petechiae and ecchymoses frequently
appear on the body. They are probably due in part to mechanical
congestion, and partly to some depraved condition of the blood.
The spleen is generally enlarged. According to the observations of
Frerichs, Bamberger, Opholzer and Wagner, enlargement of the spleen
is absent in only about 20 per cent. of all cases. The enlargement is
not great, seldom exceeding two or three times the normal size of the
organ.
In some cases the increase in size is not perceptible by reason of the
great distension of the abdomen from flatulence and effusion of serum.
Occasionally the splenic tumor is of considerable size, extending down-
ward as far as the umbilicus.
The functions of the kidneys are not seriously disturbed. In the
more advanced stages of the disease the urine is diminished in quantity
and of a reddish-yellow or red color. In the early stages the secretion
is nearly normal in quantity and appearance.
Physical Signs.-In those cases which begin with inflammatory
action, the liver, in the first stages, will be found increased in size, and
with an enlargement of the area of dulness; but as the disease pro-
gresses, the enlargement gradually recedes. Atrophy begins in the
left lobe and secondly involves the right. As the left lobe shrinks,
there is absence of dulness on percussion between the right lower
margin of the ribs and the ensiform cartilage, while the area of dulness
in the right hypochondriac region will be nearly normal. As the
atrophy increases, the right lobe contracts from below upwards until
only a narrow band of dulness is perceptible. The shrinking of the
liver, as a rule, proceeds slowly; only in exceptional instances is the
reverse the case.
It is often difficult to accurately determine the decrease in size for
DISEASES OF THE ORGANS OF DIGESTION.
907
the reason that the liver retracts more and more beneath the ribs, and
the accumulation of ascitic fluid may cover it.
The diminution in size can generally be determined most satisfac-
torily after paracentesis, and it is also possible to perceive at the same
time nodules in the form of small prominences varying in size from a
pea to a small marble. In some instances the nodules are arranged
in well-defined groups. At points where the liver lies in contact with
the abdominal parietes a friction or grating sound will sometimes be
heard, caused by the roughening of the peritoneal surfaces from the
effusion of lymph. The sound indicates perihepatitis.
As the disease advances to a fatal termination, the emaciation and
debility of the patient increase. The pulse becomes more feeble and
rapid, the appetite fails, and symptoms of complete exhaustion
appear.
The general aspect of the patient is characteristic. The skin is
sallow, the countenance pinched and shrunken, the upper part of the
body emaciated, offering a striking contrast to the cedematous legs and
distended abdomen, the skin spotted with petechiæ, and marked over
the abdomen with meandering and distended veins.
Duration.-Cirrhosis is a disease of slow progress. It is frequently
protracted to a period of two or three years from the occurrence of the
incipient symptoms to the development of portal obstruction. The
duration of the second stage is from three to twelve months. In some
instances the disease has a much briefer duration, terminating in death
within six weeks from the appearance of the initiatory symptoms.
The complications most frequently observed in cirrhosis are pneu-
monia, bronchitis, pericarditis, and erysipelas. Pneumonia is most
liable to occur in those cases of cirrhosis which have been induced by
the excessive use of intoxicating liquors, and death from an intercur-
rent attack of acute pneumonia is not an unfrequent termination.
Diagnosis.—In the early stages of cirrhosis the diagnosis is very
obscure and difficult. The symptoms do not clearly point to any
lesion of the liver, but indicate, rather, gastric derangement and a gen-
eral impairment of health.
In the first stage of slowly developing cases the disease is liable to
be mistaken for an aggravated form of dyspepsia. Usually, it is not
until symptoms of obstruction appear, evidenced by ascites and gen-
eral cachexia, that the true nature of the malady is suspected. The
habits of the patient, or a known exposure of some duration to ma-
larial influences, followed by the symptoms already detailed as belong-
ing to the first stage of cirrhosis, should lead us to suspect that degen-
erative disease of the liver has commenced. Thierfelder observes in
regard to the diagnosis of cirrhosis (Ziemssen's Cyclopædia, vol. 9, page
201): the diagnosis does not amount to a certainty, however, strictly
speaking, until we have succeeded in feeling the granulations.
908
A SYSTEM OF MEDICINE.
The diagnosis is often first of all rendered possible by puncture, not
only from the circumstance that immediately after the evacuation of
the peritoneal transudation the abdominal integument, then relaxed,
permits, as a rule, the manipulation of the liver, but also because pre-
vious thereto we are often quite unable to define with certainty the
size of the organ. Where we succeed in demonstrating only the di-
minished volume and increased consistence of the liver, but not the
granulated condition of its outer surface, it must then remain undeter-
mined whether we have to deal with cirrhosis or that form of chronic
perihepatitis extremely rare no doubt-in which, owing to the great
shrinking of the thickened capsule, a diseased condition is developed,
completely analogous in other respects to that of cirrhosis. Moreover,
two other diseases of the liver, which likewise occur far more rarely,
indeed, than cirrhosis, are occasionally so similar to it in appearance.
that they can be distinguished only when we have an opportunity of
tracing their course, or when the etiology furnishes a sufficient clue;
these are occlusion of the portal vein by adhesive thrombi, or by com-
pression, or by simple atrophy of the liver. The occlusion of the portal
vein appears invariably as a secondary lesion consecutive upon other
chronic diseases of the abdominal organs, and is usually followed by
a more rapid development of the symptoms arising from mechanical
obstruction than is cirrhosis; but on the other hand, this lesion never
gives rise to enlargement of the liver, nor, indeed, to such remarkable.
lessening in size as frequently takes place in cirrhosis.
In simple atrophy which occurs almost exclusively in decrepit
persons, and in which it is only in exceptional instances that ascites
supervenes earlier than anasarca, the reduction in volume proceeds at
a uniform rate in both lobes; in cirrhosis, on the other hand, it is, as
a rule, quite far advanced in the left lobe, when in the right it first be-
gins to be perceptible. Diffuse chronic peritonitis-the simple form as
well as the tuberculous and cancerous variety-presents, moreover,
under certain circumstances a complication of symptoms which render
the diagnosis from hepatic cirrhosis extremely difficult. Where there
exists an abundant exudation the fluctuation may be as evident and
as extensive as in ascites, while the liver, being forced upward and
backward, may be apparently diminished in size; here enlargement
of the spleen may also be present (especially in tuberculosis, but also
-according to Galvagni-in simple peritonitis), while the sensitiveness
of the abdomen is wanting.
In cases of this class a careful consideration of the remaining con-
ditions will occasionally aid us in forming a correct diagnosis. Simple
and tuberculous peritonitis are, as a rule, attended with fever, and the
skin does not present that dirty-yellowish hue observed in cirrhosis,
but is simply pallid; in tuberculosis and cancer of the peritoneum there
are also commonly found in other organs changes important as regards
DISEASES OF THE ORGANS OF DIGESTION.
909
the diagnosis (caseous deposits in the epididymides and lymphatic
glands, carcinoma of the abdominal viscera and of the mammæ).
The cyanotic atrophy and induration of the liver is characterized, in-
deed, in common with genuine cirrhosis, by a gradual reduction in the
volume which is usually at the outset enlarged, and by the presence
of ascites; but here the anasarca precedes the ascites, and the depen-
dence of the symptoms upon the insufficient action of the right ven-
tricle may be determined with certainty from the appearances found
in the circulatory and respiratory organs. A persistent occlusion of
the large excretory bile-ducts which ultimately gives rise, likewise, to a
gradual reduction in the size of the liver, is distinguished-indepen-
dently of the symptoms of the highest grade of biliary obstruction which
may also be present in cirrhosis in consequence of complications-
from the latter by the circumstance that it does not induce swelling
of the spleen, and that ascites is either absent or falls far short of at-
taining that height usually met with in cirrhosis.
In brief, the symptoms upon which a correct diagnosis can be
found are greatly diminished size of the liver, nodular feel of the
organ, ascites, enlargement of the superficial veins, oedema of the lower
half of the body, emaciation, sallow, dirty complexion, and cachectic
appearance of the patient.
Prognosis. The prognosis is exceedingly grave, particularly in
the case of patients addicted to the excessive use of intoxicating
liquors.
Although life may be prolonged for several years, and in some cases.
there may be remissions of the graver symptoms, yet a favorable ter-
mination of the disease can be rarely looked for. I have not been
able to find a well-authenticated case of recovery from cirrhosis after
the diagnosis had been well established. The prognosis generally re-
lates to the time the patient may survive under careful and judicious.
treatment and nursing, rather than to the ultimate termination of the
disease. Should a free collateral circulation be established, the prog-
ress of the disease will be much slower. Cases are recorded in which
the ascites and oedema have disappeared for an indefinite period in
consequence of a free circulation being established through the collat-
eral blood-channels.
Death may occur from exhaustion in consequence of extreme ema-
ciation and debility, or may be caused by one of the complications of
the disease. In some cases death comes suddenly from profuse hæm-
orrhage of the bowels or from hæmatemesis. In other cases delirium,
convulsions, or coma usher in the final scene, as in acute yellow
atrophy.
Treatment. The importance of an early diagnosis is in no disease.
more evident than in cirrhosis, for if any treatment is likely to be of
benefit it must be directed against the disease in its first stages. When
910
A SYSTEM OF MEDICINE.
cirrhosis is fully established, and symptoms of obstruction of the portal
circulation manifest themselves, our best-directed efforts are of little
avail to arrest its progress.
When a confirmed drinker begins to exhibit symptoms of severe
gastric derangement, together with some enlargement of the liver and
manifest disorder of the hepatic functions, it may reasonably be sus-
pected that cirrhosis is impending. If he is warned by the physician
of the threatened danger, he may heed the warning and, by promptly
abandoning his cup, escape the disease.
If cirrhosis is a sequel of syphilis or of malarial fever, remedies suit-
able to combat the effects of these diseases should be administered,
and in this latter case the patient, if dwelling in a malarious locality,
should be advised to seek a more healthy residence. Independent of
the morbid condition of the liver, the great number of accessory symp-
toms will require individual treatment, such as dyspepsia, constipa-
tion, diarrhoea, icterus, ascites, oedema, hæmorrhages, petechiæ, etc.
Appropriate remedies for each of these conditions will need to be ex-
hibited when indicated. It will hardly be necessary, neither would
it be easy to call attention to the special indications for the remedies
to meet the varying symptoms of the malady.
I would suggest Nux vomica on account of its well-known antago-
nism to the injurious effects of alcoholic excesses and malarial cachexias,
and also for its curative action in constipation and dyspeptic symp-
toms; Mercurius and Kali hyd. as anti-syphilitic remedies when the
disease shows evidences of syphilitic origin; Arsenicum and Cinchona
during the stage of enlargement of the liver, and also when the disease
is attended by hypertrophy of the spleen.
These remedies are also used when cirrhosis can be traced to the
effects of malarial poison. Bryonia and Chelidonium for hepatic pains;
Apis and Apocynum for serous effusions into the peritoneal cavity and
connective tissues; Digitalis for cardiac complications and debility.
The only remedy likely to arrest the progress of atrophy is, I think,
Phosphorus. In the exhaustive provings of this drug I find the fol-
lowing: Dulness over the liver, increasing (fifth day); the next even-
ing the lower margin of the liver could be distinctly felt above the
navel; on the seventh day the margin of the left lobe of the liver
could be felt three inches to the left median line, and dulness over the
liver extended above the fifth rib; diminution in the volume of the
liver took place the twenty-third day; on the seventy-ninth day dul-
ness over the liver was found to be unnaturally small; there was none
to the left of the median line.
These symptoms correspond to those cases of cirrhosis in which en-
largement of the liver is followed by atrophy.
For the complications which may supervene during the course of
cirrhosis, such as pneumonia, bronchitis, pericarditis, erysipelas, etc.,
•
DISEASES OF THE ORGANS OF DIGESTION.
911
the same treatment is required which is indicated in the same diseases
occurring primarily.
Other remedies to be considered are: Arsenicum, Nitric acid, Plum-
bum, Aurum, Lachesis, Iodum, Conium, Podophyllum, Argentum nitricum,
Lycopodium. The totality of symptoms must guide in the choice.
If the accumulation of fluid in the abdominal cavity is large and
becomes a source of serious inconvenience, or even danger, to the pa-
tient on account of the distressing dyspnoea arising from the pressure
upon the diaphragm and heart, paracentesis should be performed.
The operation should, however, be deferred as long as practicable, for
experience has demonstrated that the fluid re-accumulates very rapidly,
necessitating a second tapping in a week or two. Nevertheless, cases
are recorded in which after repeated tappings the ascites has disap-
peared for a considerable period.
Although the operation affords decided relief in many respects, yet
it is generally followed by increased weakness in consequence of the
loss of albumen caused by the rapid secretion afterwards.
But frequently paracentesis is the only alternative-the pressure of
the effusion so greatly impeding respiration as to endanger life. The
operation may be performed with a small-sized trocar or as I prefer
-with the aspirator, using the largest needle. With the latter instru-
ment the fluid escapes slowly, thereby greatly lessening the liability
to syncope. There is comparatively little risk of peritoneal inflamma-
tion or erysipelas.
An additional advantage in the employment of the aspirator is that
its use is attended with little pain and discomfort.
FATTY LIVER.
Synonyms. Hepar adiposum, Adiposis hepatica, Degeneratio
hepatis adiposa.
Definition.-Fatty liver is that form of hepatic degeneration which
is characterized by the accumulation of a large amount of fat in the
parenchyma of the gland, accompanied by a symmetrical enlargement
of the entire organ. As the fat globules are deposited in the secreting
cells of the liver, and increase at the expense of the proper substance
of the gland, it has happened in rare instances that the pressure thus
caused has resulted in absorption of the real hepatic tissue, and so
brought about a condition of atrophy instead of hypertrophy. But
these cases are the extremely exceptional cases, and fatty liver is always
classed among those diseases which produce enlargement.
The bare fact of the presence of fat in the liver is not sufficient to
warrant the conclusion that disease exists, for the normal construction
of the liver includes four per cent. of fat; and the ingestion of a large
912
A SYSTEM OF MEDICINE.
amount of fatty matter may be followed by the temporary presence
of an increased amount of fat in the liver. A distinction should be
drawn just here, which is very helpful toward an easy apprehension
of the true significance of an unusual deposit of fat in the substance of
this gland.
This distinction turns upon the difference between fatty infiltration
and fatty degeneration. When the accumulation of fat in the hepatic
substance is symptomatic of a destructive pathological process, it is
proper to speak of it as fatty degeneration. When some passing cause,
as an excessively fatty dietary, sends into the liver a surplus of oil
globules, which are speedily removed and are the expression of no
really pathological condition, it is equally proper to denominate this
state of affairs fatty infiltration. The cases of fatty liver found in
course of post-mortem examinations held upon the persons of those
killed by accident when in the full tide of health, should be classed
under the latter head. But this distinction cannot be demonstrated
in the living subject, for fatty infiltration has no subjective symptoms,
and does not go far enough to attract attention by enlargement of the
organ. Even fatty degeneration is not easily recognized, so that the
distinction between the two is not clinical, but explanatory.
Etiology. It is hardly possible to touch upon the causation of
this disorder without having brought to mind the Strassburg geese. It
is with the name of this city that that peculiar mode of fattening these
fowls which has for its special object the production of a greatly en-
larged liver is most familiarly associated, though the ancient Romans
were no strangers to the practice. The plan pursued is to confine the
fowls in a dark place, deny them all opportunity for excrcise, and
stuff them with food to the last degree, even to pushing it down their
gullets. This results in fatty degeneration of the liver with enormous.
enlargement, and the gland in this condition is esteemed a great deli-
cacy. It has been asserted that by confining the geese and exposing
them to an elevated temperature continuously sustained, and at the
same time depriving them of all food, febrile action and emaciation
are set up, and great enlargement of the liver produced. Conceding
this account to be reliable, it is yet a fair question to ask what is the
pathological condition thus forced upon the liver. When we consider
the ordinary method of producing hepatic degeneration in the goose,
it is at once apparent that the human goose, by virtue of his anserine
qualities, is liable to suffer a similar affliction. Those whose chief de-
light in life is found upon the dinner table, and whose chief abhorrence
is physical and mental exercise, have no right to be surprised if they
eventually find themselves in the condition of the Strassburg geese.
The use of alcoholic liquors, a habit which is so full of promise of
various hepatic diseases, is another cause of this disorder. Frerichs
ranks it high among the known causes, placing it next to tuberculosis.
DISEASES OF THE ORGANS OF DIGESTION.
913
In a second class of causes the responsibility rests with associate dis-
orders, and not upon indolent habits of life or upon a faulty dietary.
In the majority of cases fatty liver is a secondary disease, the primary
affections being tuberculosis, cancer, gastric ulcer, or chronic dysentery.
The occasional association of fatty degeneration with the three last-
named disorders has been seen often enough to call attention to the
fact, but has not been sufficiently investigated to develop facts of
special interest. Its association with tuberculosis, however, is a point
of much aetiological importance. A French physician, Louis by name,
first called attention to the frequency with which fatty disease of the
liver follows in the wake of tubercular phthisis. In his examina-
tion of tuberculous subjects he found fatty liver coexisting in about
thirty-three per cent. It has been shown that the significance does
not lie in the fact that the primary disorder is pulmonary, but in its
tubercular nature, for pulmonary maladies other than the one signal-
ized by deposit of tubercle are accompanied by no such hepatic de-
rangement; on the other hand, let the tuberculous deposit take place
elsewhere than in the pulmonary tissue, in the mesentery for instance,
and the liver is as liable to suffer as though the tubercles were in the
lung. So intimate is this connection between the tuberculous diathesis
and fatty degeneration of the liver, that it has been recognized by all
observers, and authorities are pretty well agreed that the existence
of the former is the largest factor in the etiology of the latter.
Pathology. To some extent the presence of uncombined oil or
fat in the human liver is a normal condition, being usually about
equal to three or four per cent. of the whole liver substance, the secret-
ing cells of the liver being at certain times and under certain circum-
stances constantly filled with fat. It is reasonable, therefore, to infer
that the fat thus contained in the liver is necessary for the due per-
formance of the functions of that organ; nevertheless, an increase of
fat beyond a certain amount undoubtedly constitutes an abnormal
condition, and we may only judge where to draw the line between
health and disease by the morbid phenomena which an undue amount
of fat in the liver creates. From his extensive observations Frerichs*
concludes that the fatty contents of the liver rise and fall in relation
to certain definite periods of development, and that these are possibly
influenced by pathological conditions. It is altogether probable that
the quantity of fat in the same person, in health, varies considerably
at different times, according to variations in diet and other conditions,
which will be hereafter considered. The deposition of fat is always
limited to the secreting cells, never being found in the intercellular
spaces. It is present in an oily or fluid shape, solid granules of fat
being rarely found. The accumulation of fat usually causes the cells
*Op. cit., p. 197.
VOL. I.-58
914
A SYSTEM OF MEDICINE.
to enlarge, and when the disease is in an advanced stage their form
is altered, their angular outlines disappearing, and the cells assuming
a rounded form; when the accumulation of oil-matter is very consid-
erable, the outer surface of the cell assumes an uneven character from
the projecting oil globules. In proportion to the increase of the fatty
matter, the remaining contents of the cells recede, and soon no trace.
of them is to be found.
Frerichs* distinguishes three stages in the development of fatty
liver. In the first stage, the cells in the neighborhood of the ramifica-
tions of the portal vein become fatty, and this abnormal appearance
gradually disappears towards their centre, the cells being here partly
normal in their characters, but for the most part loaded with pigment.
In the second stage, the deposit of fat advances more than half way
to the centre of the lobules, and it is only in the immediate neighbor-
hood of the central veins that we can detect cells still containing pig-
ment and free from oil. In the third stage the change extends as far
as the central vein. In well-marked fatty liver, post-mortem examina-
tion reveals enlargement and increase of weight of the organ, though
the specific gravity is diminished, the organ sometimes being so light
as to float on water. The margins lose their natural sharpness, and
become thickened and rounded, and the surface is smooth. The en-
largement is usually uniform, and the inferior border may extend
more or less below the false ribs. A whitish or yellowish color, with
opacity, prevails both externally and on section, this being generally
mottled with red. Rokitansky describes the color to be like autumnal
foliage. There is softening of the tissue, which has a doughy, inelastic
feel, pits on pressure as in oedematous parts, and it readily breaks
down or tears. The organ is anæmic, but little blood escaping from
the cut surface. There is a loss of distinctness of outline of the lob-
ules, and evidences of the presence of much fat may be obtained either
by the knife, by blotting-paper, or by ether. A piece of the diseased
structure held in flame, after the water is driven off, burns readily,
throwing off blue sparks. A thin slice placed on a piece of white
paper and exposed to heat, exudes oil in abundance, greasing the paper.
The cut surfaces give to the finger passed over them an unctuous feel.
Fat adheres to the scalpel in making the incision. The liver may
yield as much as from 43 to 45 per cent. of oily matters, which consist
of olein and margarin, with traces of cholesterine. Microscopical ex-
amination shows enlargement of the cells, which also become spherical,
and are more or less loaded with fat. In advanced cases this may
sometimes be observed without the aid of the microscope, but the
latter is the most reliable test for the presence of fat in the hepatic
cells, and it is altogether probable that before the microscopic test was
* Op. cit., p. 205.
DISEASES OF THE ORGANS OF DIGESTION.
915
employed, other conditions were not unfrequently confounded with
fatty liver.
Symptomatology.-The symptomatology is singularly meagre.
There are no subjective symptoms. In extreme cases there may be
some sensation of weight and heaviness in the right hypochondrium,.
but even then there is no pain, neither is pain caused by thorough
manipulation. The objective symptoms are those of a symmetrically
enlarged liver. The surface is smooth, the edge blunted or rounded,
the consistence soft and lax. The skin presents a change to the eye,
assuming a semi-transparent and waxy appearance; and to the touch,
under which the sensation is unctuous, velvety, or satin-like. Addison
was so enthusiastic over this cutaneous condition as to call it "pathog-
nomonic." If the pressure within the substance of the liver be suffi-
cient to impede the blood in its passage through the capillaries, and,
therefore, through the portal vein as well, the resulting hindrance of
the abdominal circulation may set up an irritation of the stomach, or
an irritation of the intestinal tract, finding expression in diarrhoea, or
distend the veins of the rectum to such a degree that hæmorrhoids
are the consequence. Further than this there are no symptoms which
are more than occasionally present. Ascites is rare, and jaundice is
usually wanting, and always slight.
Diagnosis. The diagnosis of fatty liver is no easy matter. Though
we may fancy that we have that peculiar condition of the skin be-
longing to this disease, yet the enlargement of the liver is the leading
physical sign. The peculiarities of this form of enlargement are its
thickened border, smooth surface, and softness under pressure. This
seems to distinguish it from cancer of the gland, with its familiar
hardness and nodosities. Cancer elsewhere is sometimes accompanied
by fatty liver, and is even considered one of its causes. The waxy
liver attains greater size, is harder, and more tense.
In this poverty of diagnostic signs, when determining the presence
of this disorder, dependence must be largely placed upon our knowl-
edge of its causes. These causes have already been detailed and, with
the frequent tendency to a coincident deposit of fat in other tissues,
must enter largely into a diagnosis which must be one of probabilities
rather than demonstration.
Prognosis.-There is no immediate danger, and almost no ulti-
mate hope. When secondary to such a disease as phthisis, whose
hopeless prognosis is a matter of universal knowledge, there can be
no hope of recovery. In those exceptional cases where the disease is
idiopathic, and reformation of habit regarding eating, exercise, and
the drinking of liquors promises to remove the greater part of the
cause, there is just reason to anticipate that the disease may be kept
at bay. Be the cause what it may, there is no probability of a sud-
den fatal termination, as from the rupture of an hepatic abscess or
ง
916
A
A SYSTEM OF MEDICINE.
hydatid. The final issue of the case is, however, always unfavora-
ble.
Treatment.—When the disease is the penalty for violation of
hygienic laws, the treatment consists in the establishment of proper
habits of life. Over-eating should be supplanted by a diet from which
are excluded fats and the fat-producers; total abstinence must be
rigidly enforced. Indolence should give place to exercise, caution
being observed if there be reason to suspect that fatty degeneration.
has invaded the heart as well as the liver. As in the majority of cases
fatty liver is secondary to some other disorder, it follows that the treat-
ment must be largely directed to the primary disease. These primary
diseases being fatal, it is plainly to be seen why the therapeutics of
the hepatic affection are almost a blank, and why experience has so
little to suggest. Phosphorus is strictly homoeopathic to this disease,
and Bayes claims to have used it with satisfactory results.
CANCER OF THE LIVER.
Synonyms.-Carcinoma of the liver, Hepato-scirrhus.
Definition.-Cancer of the liver is a term needing no definition
beyond that belonging to the malignant dyscrasia whose local expres-
sion
may be at the expense of almost any organ or tissue of the body.
It is the commonest of all the hepatic disorders which involve organic
changes, cirrhosis occupying the second place in point of frequency.
Before the cancerous nature of the infiltrations, with the enlargements
and nodules of this disease, was recognized, these various lesions re-
ceived such names as tubera, steatomata, white tubercles, and hard
tumors; and the older synonymy of the disorder includes these names.
But now that the identity of the disease lying back of these appa-
rently differing conditions is clearly understood, all its manifestations
are grouped under the single designation of cancer of the liver.
Etiology. As is the case with cancer elsewhere, the only cause
decipherable is the hereditary taint. Inquiry prosecuted in directions
which promised to enlarge the boundaries of its etiology has yielded
little fruit. Sex is without influence here, the recorded cases showing
a very even balance between the male and female. Age has some
influence, as the disease is more common during the latter half of
adult life; yet it has been found in infants. When the hepatic can-
cer is secondary to cancer preceding it in some other organ of the
body, it may be said to have an immediate cause in the primary can-
cer located elsewhere; but this statement is destitute of real ætiological
interest, and the whole subject of causation is contained in constitu-
tional dyscrasia.
Pathology.-Cancer of the liver many occur primarily, but in a
great majority of cases it is secondary to carcinoma in other parts,
DISEASES OF THE ORGANS OF DIGESTION.
917
and in one-third of the cases it has been found to be secondary to
cancer of the stomach. When primary, it is usually limited to the
liver and contiguous structures and organs, rarely spreading farther,
the peritoneum covering the liver, the diaphragm, the duodenum, the
stomach, and the pancreas sometimes becoming involved from con-
tiguity of tissue.
Cancer of the liver is very liable to develop after the extirpation of
cancerous tumors on the periphery. As a rule, it presents the charac-
ters of ordinary simple cancer, having characters intermediate between
those of scirrhus and encephaloid, approaching more towards one.
variety or the other in different instances, this preponderance being
in favor of the encephaloid or medullary variety. Usually, a cancer-
ous growth in the liver assumes the form of distinct nodules or isolated
tubercules imbedded in the hepatic parenchyma. These nodules vary
greatly, both as to size and number, being small at first, and gradually
enlarging until they may ultimately reach the dimensions of a child's
head, or even attain a larger size than this. Ordinarily, several are
found unequal in size, and by their coalescence considerable tracts of
the organ are sometimes involved. Sometimes extensive portions of
the hepatic tissue are infiltrated with cancerous matter, without any
definite line of demarcation. Originally the shape of the nodules is
rounded, but when they reach the surface they become flattened or,
in many cases, depressed and umbilicated, presenting shallow con-
cavities. This umbilication is produced by a fatty metamorphosis of
the centre of the mass and contraction of the peripheral portion. The
peritoneum is usually adherent, and is cloudy, thickened, and covered
with a membranous exudation; but it may remain normal. The
nodules, as a rule, are not separated from the surrounding tissue by
any definite structure, but occasionally a distinct cyst exists around a
cancerous mass. Usually the consistence of the mass is moderately
firm, but it may range from that of a soft, brain-like, semi-fluctuating
substance to a hard cartilaginous tissue, and the amount of cancer-
juice which can be expressed will vary accordingly, being in propor-
tion as the cancerous growth is soft and medullary. The color, on
section, is in most cases white, or yellowish-white, but more or less
dotted and streaked with red, on account of the vessels present; it
may, however, be extremely vascular and dark red, resembling "fungus
hæmatodes." The liver is usually enlarged in proportion to the num-
ber and size of the growths, being often extremely large and heavy,
as well as irregular in shape. Its tissues are more or less destroyed
and compressed, the vessels and ducts are encroached upon or oblit-
erated, and, as a consequence, jaundice and signs of obstructed circu-
lation are often present. Sometimes thrombosis occurs in the portal
branches or trunk. New vessels are developed, formed by the hepatic
artery. These vessels vary greatly in number, being most numerous
918
A SYSTEM OF MEDICINE.
in the medullary varieties. Sometimes they are aggregated together
in such large numbers as to cause the mass to have a dark-red hue, as
before mentioned.
The explanation of the origin of the growth differs, some observers
holding that it begins in the centre of the lobules, but it is pretty
generally admitted that the morbid change originates in the inter-
lobular connective tissue.
The new vessels developed from the hepatic artery have very deli-
cate walls and are liable to rupture, infiltrating the mass with hæmor-
rhagic extravasation. When the periphery of the organ is reached by
the new formation, hæmorrhage may take place into the peritoneum,
and sudden death ensue from this cause.
When the cancerous deposits are near the surface of the liver, the
serous covering is usually involved, localized peritonitis being excited,
with consequent thickening and adhesions. Neighboring tissues may
be involved by extension, and the lymphatic glands in the portal fis-
sure are often implicated.
Rokitansky describes a form of hepatic cancer which he calls "in-
filtrated cancer," in which large portions of the liver are found con-
verted into a white cancerous mass. The obliterated vessels and gall-
ducts, which are surrounded by rudimentary liver-cells atrophied,
fattily degenerated and colored by bile, often traverse this white mass
as a coarse yellow framework. Towards the periphery the infiltrated
cancer gradually passes into the normal parenchyma, as there are
places where cancerous masses, and others where the liver-cells, are in
excess. The growth of hepatic cancer is sometimes extremely rapid,
especially in the soft variety, but hard scirrhous cancers increase very
slowly. The increase, in most cases, seems to take place in paroxysms,
periods of apparent repose alternating with others in which the nod-
ules are painful and grow rapidly. Changes indicative of retrograde
metamorphosis and decay occur in hepatic cancer just as in the same
form of disease situated in other organs and tissues of the body.
According to Frerichs* these changes consist in fatty degeneration of
the carcinoma, as well as in its atrophy and shrivelling up. The cells
lying in the meshes of the fibrous stroma become filled with oil-
globules, and present a white opaque appearance; in this way the
cancer structure assumes a reticulated aspect, or, owing to the atrophy
of large groups of cells, nodular-like masses are originated. Ulti-
mately the fatty cells may become disintegrated, and as a conse-
quence an emulsive fluid may be formed, which gradually undergoes
absorption. These changes occur chiefly in the central portions of the
morbid growths, and the fibres of the reticulated stroma, when they
take place, are densely aggregated, the meshes becoming smaller
until there remains only a firm, cicatrized tissue, yielding on pressure
* Op. cit., p. 48.
DISEASES OF THE ORGANS OF DIGESTION.
919
no cancer-juice. These changes have been regarded by Oppolzer,
Bochdalek, Hughes, Bennett, and others, as indications of the com-
mencement of cicatrization and spontaneous cure of hepatic cancer.
Frerichs doubts the conclusions to which these observers have
come, and thinks they may have confounded carcinoma with the
syphilitic cicatrices of the liver, the nature of which is now much
better understood than formerly. He states that although the retro-
grade change may be distinguished in the centre of the cancerous
nodule, a progressive development of disease is observed at the cir-
cumference; and from this he concludes that the morbid action has
not expired, but is only locally destroyed. Melanotic, cystic, and
colloid or alveolar cancers are so unfrequently found in the liver that
their pathological peculiarities do not require special mention.
Symptomatology.-The enlargement and asymmetry of the or-
gan, and the pain and tenderness experienced in this region, are the
most important symptoms. While in rare cases the enlargement has
been absent, and the diagnosis consequently obscured, yet the increase.
in size is a very constant symptom, and has its notable peculiarities.
These are loss of shape in general outline through hypertrophy of a
single lobe or portion of the liver, and deformity of its surface from
the formation of nodules or tuberosities which sometimes become
sufficiently prominent to be visible through the abdominal walls.
Either or both of these peculiarities may be present in a given case;
or the fact that the liver is misshapen may not be made out so clearly
as the simple fact of general enlargement.
This process of enlargement is usually a rapid one, and the size.
attained is often very great, a case being on record in which the gland
reached a weight of 15 pounds. Under palpation, the sensation com-
monly imparted is that of a body of considerable hardness, the ex-
ception being with the medullary variety of the disease, which is
softer and may even afford fluctuation. The pain so characteristic
of malignant growths, and the tenderness on pressure, become symp-
toms of moment because they are full of meaning as to just what is
going on within, and offer a marked contrast to waxy and fatty degen-
eration and to hydatid disease.
These two chief symptoms, the objective symptom of enlargement
and the subjective one of pain, are flanked on either side by another
set of symptoms, one belonging to the early stage, and one to the
latter stage of the disease. The early symptoms are those of deranged
digestion; the bowels are distended with gas, the eructations showing
its fetid nature; the appetite fails, there are nausea and vomiting and
constipation. The group of symptoms appearing in the latter stage
is made up of an excited and irregular heart-beat, dyspnoea, emacia-
tion, a colliquative diarrhoea which has taken the place of the earlier
constipation, the cancerous tinge of the skin, exhaustion, and death.
920
A SYSTEM OF MEDICINE.
Certain other symptoms are occasionally present, but are of minor
importance. Among these is jaundice, which may be caused by the
incidental occlusion of a biliary duct from pressure exerted by an
enlarged lymphatic gland, although the most extensive destruction of
the hepatic tissue may fail to induce it. Once appearing, the jaundice
never disappears. Whether it be present or not, the urine is scanty
and high-colored. Ascites and cedema of the extremities are also
occasional symptoms.
These various symptoms and sets of symptoms may extend over a
few weeks, or be drawn out over as many months; but it is not often
that the disease exceeds a year in duration, its course being compara-
tively rapid. Perforation of the diaphragm, rupture of the tumor,
emptying its contents into the peritoneal cavity, and inflammation of
the pleura or peritoneum, are accidents which are immediately fatal.
But these accidents are exceptional, death usually resulting from the
slower process of exhaustion.
Varieties. Cancer of the liver may be either primary or second-
ary. When primary, there is developed but little tendency to the
lighting-up of cancerous inflammations in other quarters of the body,
only those tissues lying in the immediate vicinity being liable to
suffer. The structures thus liable to invasion by reason of their con-
tiguity, are the peritoneal covering of the liver, the duodenum, the
stomach, the diaphragm, and the pancreas.
More frequently, however, cancer of the liver is a secondary affec-
tion; the primary seat of the disease being then, in most cases, in the
stomach, pancreas, spleen, or intestine. These. organs all belong to
the portal system, and it has been remarked by various observers that
secondary cancer of the liver follows, in a majority of cases, cancer of
some viscus whose venous blood is poured in upon the liver. Frerichs's
table of ninety-one cases of hepatic cancer shows forty-six to have
been inaugurated in the secondary manner through the portal system,
thirty-four of these originating in the stomach. Twenty-three other
cases, out of the ninety-one, were secondary to cancer occurring out-
side of this portal circle of the circulation, leaving but twenty-two
cases in which the cancer of the liver was the primary manifestation.
Those cases in which the hepatic affection is secondary, and yet the
primary disease is not within the portal system, will be found to have
followed cancer of the mamma, lung, uterus, ovary, testicle, kidney,
bone, or skin.
Turning from the division into primary and secondary cancer to
question the exact nature of the cancerous growth, it is discovered that
the varieties exhibited in the liver are coextensive with all the known
varieties encountered in other localities. Scirrhus and medullary are
the commonest forms, but cases have been reported embracing all the
other varieties.
DISEASES OF THE ORGANS OF DIGESTION.
921
Diagnosis.-Like the other organic diseases of the liver, cancer in
its earliest stages has nothing to offer whereby a correct diagnosis
might be reasonably assured. The first symptoms are quite as sug-
gestive of gastric disturbance as of hepatic mischief. But when the
disease has progressed so far that the nodulated enlargement becomes
apparent, no hepatic disease of an organic nature is easier of diagnosis.
The enlargement, its lumpy, uneven character, the pain and tender-
ness, and the general cancerous cachexia make up a group of phe-
nomena not liable to be mistaken. It is true that in very exceptional
cases there is no enlargement; but even then the pain and tenderness
will help determine the nature of the case, for painfulness becomes a
significant symptom in an organ so wonderfully tolerant as is this,
and such authorities as Frerichs and Da Costa agree that this is the
most constant of all the symptoms of this disease. While care and
discrimination are required, it is only exceptionally that the diagnosis
cannot be made with a good degree of certainty.
Prognosis. Rarely exceeding one year in duration, and, at times,
completing its work within a few weeks, the termination is uniformly
and invariably fatal. The prognosis is at once certain and prophetic
only of death.
Treatment. Without hope of curing the patient, there yet re-
mains much to be done toward mitigating the miseries of the sufferer.
The derangements of digestion and nutrition afford a very considera-
ble field in which the proper remedies are not slow to show their use-
fulness; these are more especially Nux vomica, Ipecacuanha, Pulsa-
tilla, Antimonium crudum, Carbo vegetabilis, and Arsenicum. The
special indications for such familiar friends on such familiar ground.
need not be here rehearsed. In addition to the use of these remedies,
supervision of the diet is important, lean meats, soups, vegetables,
bread, and milk being the most desirable forms of food; these must be
taken in small quantities and frequently.
Pain and sleeplessness are harassing accompaniments which demand
relief. This is best accomplished by the use of Opium and the second
decimal trituration of Atropine in such doses as may be adequate for
the purpose. In those cases where ascites is present, and in such de-
gree as to be burdensome from its weight and effect upon respiration,
the fluid should be removed. This is done with little pain and perfect.
safety by means of the aspirator.
Nothing can be said of remedies to be applied for the direct purpose
of curing the disease. Still, one cannot readily abandon altogether
the hope that some such remedy as Conium, Hydrocotyle, Hydrastis,
or Arsenicum, may some day substantiate its claim to active helpful-
ness in this now hopeless malady.
922
A SYSTEM OF MEDICINE.
HYDATID TUMORS OF THE LIVER.
Synonyms.-Echinococcus of the liver, Hepatic cyst.
Definition.-Hydatid tumors of the liver are those cystic forma-
tions which spring up around the echinococcus when it has found its
way to, and penetrated into, the substance of the liver. The echino-
coccus is the larval form of the tænia echinococcus, or dog-tapeworm.
It is to the fully developed worm precisely what the caterpillar is to
the butterfly. In its state of complete development this variety of
tapeworm is a parasite infesting the several members of the canine.
family. But as the dog is the only member of this family which has
been domesticated, and is, therefore, the only source of human infec-
tion, this worm is commonly spoken of as appertaining to him, al-
though an exact statement would include the fox, the wolf, and the
jackal. Like the other species of tapeworm, it finds its home in the
alimentary canal; unlike the others, it never attains any considerable
size, being about one-quarter of an inch in length, and having but four
segments. While it is never found in the human intestine, yet, when
by some accident or circumstance its ova, having made their escape
with the excrementitious matters of the dog, find their way into the
human body, they do not find their environment so inhospitable as
to cost them their existence. They develop into the intermediate and
rudimentary form, and bury themselves in the liver, there to set up
the pathological process whose outcome is the hydatid tumor.
Etiology. It is seldom that the causes of a disease may be set
forth so definitely and satisfactorily as in the present instance. They
are: immediate cause, parasites; remote cause, dogs. This tells the
whole story. To enlarge upon these two factors would be a work of
supererogation. It might be said that the disease occurs among the
poor rather than the rich; but that is only one way of saying that the
squalid herd with dogs, eat, drink, and sleep with dogs, while the more
thrifty classes do not.
Hydatid tumor of the liver is a very rare disorder in this country.
Dr. Austin Flint makes the statement that Prof. Janeway, of Bellevue
Hospital, with the largest opportunities for post-mortem observation,
in ten years encountered but three livers so affected. A most extensive
practice will fail to encounter more than a case or two. But this is
not true of all countries. Europe seems to show a much greater fre-
quency, while Iceland bears the unenviable reputation of being its
favorite haunt. One authority states that on this island this disease
affects one-sixth of the population; another, that it is the cause of one-
seventh of the entire mortality; and a third, that the resident physi-
cians have, at times, from eighty to one hundred patients so afflicted.
With Dr. Kane's testimony as to the filthy habits of life within the
arctic circle, added to the fact that in those regions dogs bear as im-
DISEASES OF THE ORGANS OF DIGESTION.
923
portant a relation to society as does steam in our own latitude, we
need not be at a loss to know why this northern isle should be so
scourged by the ravages of this parasite.
There appears to be some connection, which has received as yet no
explanation, between external violence and the development of the
hydatid growth. Frerichs and Budd both note the fact that in quite
a proportion of the recorded cases the tumor was noticed after a blow
on the side, of which the patient supposed it to be the consequence;
of Prof. Janeway's three cases, to which reference has been made, two
had suffered mechanical injury of the liver. No plausible explanation
of these coincidences has been offered.
One other possible element in the etiology of this affection has re-
ceived considerable attention. Sheep are liable to infection with this
variety of tapeworm, its career in their organism being exactly the
same as in the human system. When a human being is thus affected,
there is no danger of his communicating the disease to any other indi-
vidual. If he dies, his disease is buried with him. Not so a sheep.
Presumably healthy, it may be slaughtered for food; and dogs devour-
ing the offal may swallow some of these echinococcus cysts. The
contained worm, theretofore immature, is now once more in its most
congenial home, and grows to maturity, thus infecting a previously
healthy dog, and creating a new centre for the dissemination of the
ova of the parasites. On this score it is held that shepherd-dogs and
butchers' dogs are specially liable to form, with the sheep with which
they come in contact, a complete apparatus for the cultivation of the
two forms of this worm. Nor is it necessary that the dogs should feed
upon the liver of the sheep, for the echinococcus is not confined to the
liver, but may be present in any viscus.
Anatomical Description and Pathology.-In most cases only
a single hydatid is developed in the liver, but they are sometimes.
very numerous, and occur more frequently in the right lobe than in
the left. In the hydatid tumors found in man there is usually seen in
the contained liquid a number, varying greatly in amount, of globular
bladders or cysts similar to that lining the sac. These small cysts are
of very different sizes, some being as small as a pea, others larger than
a walnut. These are the Acephalocysts described by Laënnec, and
which Frerichs looks upon as hydatids containing no scolices. The
anatomical characters of a typical hydatid cyst are thus described by
Roberts: 1. Externally there is a firm, whitish or yellowish, fibrous,
vascular capsule, the result of proliferation of cellular tissue from irri-
tation, which is adherent to the surrounding structures. 2. Within
this, moulded, as it were, to its interior, but easily separated from it, is
a delicate cyst or bladder, elastic, grayish, semi-transparent or gelati-
nous in aspect, and compared to boiled white of egg; under the micro-
* Frerichs, op. cit., p. 7.
†Theory and Practice, vol. ii., p. 223.
924
A SYSTEM OF MEDICINE.
scope this is seen to consist of several hyaline, concentric layers, a sec-
tion presenting a characteristic laminated appearance. The most
internal layer is extremely delicate, and is studded with minute
transparent cells. The term mother sac or vesicle is usually applied
to this structure as a whole; but it has also been limited to the
internal lamina just mentioned, likewise termed the germinal mem-
brane. 3. A quantity of fluid is contained within this cyst, usually
completely filling it, perfectly colorless, transparent, and watery, as a
rule, occasionally slightly opalescent, of low specific gravity, 1007 to
1009, generally alkaline or neutral in reaction, but occasionally acid,
and consisting mainly of a strong solution of chloride of sodium, with-
out any albumen or other organic substance, but said to contain suc-
cinate of soda. 4. Floating in this fluid, or attached to the inner
surface of the mother cyst when small, are numerous secondary or
daughter cysts; in some instances these amount to hundreds or thou-
sands, and completely fill the space, so that there is little or no fluid,
and they become flattened by natural pressure; each daughter cyst
has precisely the same structure as the mother sac, and within the
larger of them there may be a third generation, and, rarely, a fourth
is observed. 5. When the walls of the sacs are examined carefully,
little whitish opaque spots are visible on the inner surface, which are
the scolices of the echinococcus in various stages of development, usu-
ally arranged in groups or clusters, but occasionally single. These may
also be free in the fluid, rendering it somewhat opaque. Each scolex
is very minute, measuring from th to th of a line in length, but the
length and form vary according as the head is retracted into the body
or extruded. The head presents a proboscis, four suckers, with a
double circle of characteristic curved hooks, which are movable and
of unequal length; a constriction separates it from the body, the latter
being striated longitudinally and transversely, and presenting poste-
riorly a depression with a pedicle, by which the animal is fixed to the
sac in its early condition. Numerous round and oval calcareous parti-
cles are imbedded in the tissue. The size of the cysts varies greatly.
Sometimes one will attain such dimensions as to completely fill the
abdomen, and even to encroach upon the chest. The daughter cysts
usually range from a millet-seed to an egg in size, but subsequent
generations are very minute. The size, shape and appearance of the
liver varies with the number, position and growth of the cysts. With
their development the hepatic tissue is correspondingly atrophied, by
being encroached upon, while the rest of the organ remains intact, or
undergoes hypertrophy, or becomes hyperamic. The larger blood-
vessels and bile-ducts are seldom affected by the cysts, so that jaundice
and ascites rarely occur, but they both may suffer, sometimes becoming
entirely obliterated. Sometimes, by a breaking through of the bile-
duct in the course of the development of the cyst, a communication is
.1
DISEASES OF THE ORGANS OF DIGESTION.
925
established between the two, and bile entering the cyst causes an
arrest of its growth. Sometimes the vesicles escape into the bile-ducts
and, becoming impacted there, cause dilatation of the ducts, and ulti-
mately pass into the gall-bladder or the bowel, and may be thrown off
from the latter, a cure thus being effected. Sometimes, also, in the
same way, after adhesions are formed, the cyst may be evacuated into
the stomach or neighboring blood vessels; or, when the diaphragm has
been gradually thinned, and finally perforated by the pressure, the sac
may empty into the pleural cavity or into the lung adherent to the
pleura, or, more rarely, into the pericardium. Occasionally the cysts
undergo calcification, the envelope becoming thicker and tougher, and
calcareous salts being deposited; expansion and growth are prevented,
the parasites die, and are found flattened and contracted. In other
cases there is developed on the interior of the capsules a dense, honey-
like or puriform fluid, which had previously been clear, and then milky,
and remains of the scolices, especially of the hooklets, are found float-
ing in, or mixed with, the contained fluid. Crystals of hæmatoidine
and bile also are found mixed with the wasting cysts. According to
Frerichs, in a large proportion of cases the echinococci of the liver are
in this manner destroyed and become harmless. Sometimes the cyst
ruptures through the distended and thinned peritoneal covering of the
liver, the contents of the sac entering the peritoneal cavity and exciting
a severe peritonitis. Frequently local peritonitis is excited by the
presence of the enlarged organ, and thickening and adhesions occur.
Virchow describes a rare form of this disease which he called "Ulcer-
ative multilocular echinococcus-tumor," or the multilocular hydatid
cyst. The liver is found occupied by a mass, in some cases as large as
a child's head, or even larger, consisting of a stroma or cellular tissue,
usually altered considerably by fatty degeneration, in which are im-
bedded cells or alveoli of various sizes, inclosing a gelatinous substance,
microscopic examination of them revealing fragments of the laminated
membrane of hydatids, hooklets, or occasionally even perfect scolices,
as well as abundant calcareous particles. The centre of this mass is
very liable to undergo suppuration, thus altering its characters con-
siderably. This arrangement of the tumor has been attributed to the
embryos having been deposited in the lymphatics, blood vessels, or
ducts of the liver; or to the absence or early rupture of the external
fibrous cyst, so that the parasites are able to grow and migrate in
various directions, and may thus enter the different vessels.
Symptomatology. This disease is altogether destitute of symp-
toms until the hydatid has attained a size which challenges the atten-
tion by presenting a tumor or enlargement of the liver. Up to this
point there are no symptoms. There is no disturbance of hepatic
function, no jaundice, no digestive derangement, no irritation of the
* Virchow's "Archiv.," vol. xxxiii., p. 16.
926
A SYSTEM OF MEDICINE.
lung until the growth is large enough to cause mischief by its me-
chanical presence. Pain, febrile action, and constitutional depression
are entirely wanting. In this absence of any signal of distress up to
the point where the cyst reaches a certain size, it must be true that
any hydatid which halts by self-limitation before reaching this size,
necessarily passes unsuspected and unrecognized. Only those cases
can be apprehended by the physician which attain a development
great enough to exhibit enlargement and to produce disturbance. How
many cases fall short of such development and pass an undiscovered
existence, can only be a matter of conjecture. The remains of old
cysts of this sort have been more than once brought to light by post-
mortem examinations. But as these small cysts give no sign and do
not threaten life, they are devoid of clinical interest except as they
bear upon the question of the frequency of the disease.
Those cases which pass beyond incipiency, and come under the
physician's observation, present first an enlargement of the liver. This
is progressive, until either a tumor may be made out, or the enlarge-
ment of the liver becomes notable for its lack of symmetry, the increase
in size seeming all to tend toward some one quarter of the gland. The
tumor or enlargement may be projected from any aspect of the liver.
It is smooth, elastic, and somewhat soft and fluctuating. Some sub-
jective symptoms also appear, such as fulness, uneasiness, weight, and
dragging. When the growth is in the direction of the thorax, pushing
up the diaphragm, we are met with embarrassment of respiration,
cough, and cardiac irritability. If it encroach upon the stomach and
intestines, disturbances of digestion become prominent. More rarely,
pressure upon the vessels of the liver itself induces ascites or jaundice;
or crowding of the vena cava results in a swelling of the lower extrem-
ities which is partly oedematous and partly due to the varicose condi-
tion thus thrust upon the veins whose outlet is obstructed.
As a matter of course, there is a sudden accession of severe and
alarming symptoms whenever the cyst may chance to burst. When
the contents are emptied into the pericardium, the new symptoms are
those belonging to cardiac oppression and fatal pericarditis. When
into the vena cava, some secondary cyst finds its way into, and plugs,
the pulmonary artery, and death is by asphyxia. When into the
cavity of the peritoneum, the resulting peritonitis is sharp and hope-
less. When into the cavity of the pleura, pleuritis is excited, not nec-
essarily fatal, as relief may be obtained through the lung and bronchi.
Discharge into the stomach will give us vomiting; into the intestine,
no special symptom save the escape of characteristic matter per anum ;
and discharge by either of these routes may be followed by a favorable
termination.
Diagnosis. As suspicion of the presence of the disease is not
aroused until the tumor or enlargement becomes perceptible, the first,
DISEASES OF THE ORGANS OF DIGESTION.
927
and about the only, problem to be met in the diagnosis is to determine
the growth to be an hydatid rather than the product of some other
disease of the liver accompanied by increased size. The task is not a
difficult one. The affections which, by reason of the enlargement they
produce, present themselves for exclusion, are abscess, cancer, waxy
and fatty degeneration, and distension of the gall-bladder. An abscess.
so prominent as to present a tumor-like appearance is an abscess so
well marked that the ordinary constitutional and local symptoms could
not well be absent, to say nothing of the slow evolution of the hydatid
as compared with the rapid course of abscess. It is true that suppu-
rative inflammation has been set up within the hydatid tumor, when
differential diagnosis is scarcely possible even with the aspirator. But
in such an event the hydatid disease is, to all intents and purposes,
transformed into an hepatic abscess; and to so diagnosticate would be
clinically correct, though it might be considered theoretically inexact.
The cancerous growth is painful, nodulated or lumpy, and hard,
all three of which characteristics are in sharp contrast with those of the
hydatid. The latter is painless, presents a smooth surface, and is soft
enough to yield fluctuation. This fluctuation is peculiar, and has
been described as the "purring tremor," "thrill," or "fremitus," and
likened to the sensation imparted by the trembling of a mass of jelly.
It is best obtained by placing two or three fingers flat on the surface,
directly over the growth, and by striking them sharply, while held
firmly in position, with the fingers of the other hand. Frerichs re-
cords a case of hydatid disease mistaken for cancer, because of the ex-
istence of pain; but it is very rarely that pain is attendant upon the
growth of this cyst, and, taken with the other points of difference, mis-
take is unnecessary. Waxy and fatty degenerations are distinguished
from hydatid disease by the symmetrical enlargements of the two
former, and the altered shape of the liver, or tumor, resulting from the
latter. A distended gall-bladder should be known by its situation,
shape, accompanying jaundice, and attacks of colic.
Pleuritic effusion may simulate hepatic enlargement by increasing
the area of percussion dulness, and so possibly suggest the presence of
a cyst projecting from the superior surface of the liver and pushing its
way upward. But in effusion the upper boundary line of dulness,
when the patient is in the erect posture, is horizontal, and is changed
by the assuming of a recumbent position, while the hydatid shows an
arched outline unaffected by change of position.
The pulsation and pain of aneurism of the aorta are points of differ-
ence ample for the avoidance of blunder in this direction. But if,
even in the face of these marks of distinction between hydatid and the
various other disorders, doubt still lingers in the mind of the physician,
the aspirator will readily settle the matter, for the fluid from the cyst
will show itself clear and transparent, remarkable alike for the absence
1
928
A SYSTEM OF MEDICINE.
of albumen and urea, and the presence of chloride of sodium. In the
words of Murchison, "These characters apply to no other fluid in the
body, whether healthy or morbid. Even if the case should turn out
to be an aneurism or cancer, no harm is likely to result from an ex-
ploratory puncture.'
""
Prognosis. The prognosis is very grave. In occasional cases of
great rarity, while yet the hydatid is small, the contained echinococci
die, and the growth undergoes a retrograde metamorphosis. Except
in such cases, the tumor gradually but steadily enlarges until it bursts,
unless there be operative interference. If it attain great size before
bursting, there may be danger from the high degree of pressure exerted
in this busy and important region. When it bursts, there are so many
chances for death from a discharge into cavities or vessels unable to
withstand the shock of such intrusion, to the one single chance of dis-
charge by a less dangerous route and final recovery, that the greater
probability does not lie on the side of recovery. In the fact of a cir-
cumscribed collection of fluid in the liver, in the identity of the possi-
ble and probable destinations of the fluid when it escapes from its
confinement, and in the serious aspect of the prognosis, hydatid disease.
bears a striking likeness to hepatic abscess. The resemblance also ex-
tends to the influence for good which the prompt use of the aspirator
exerts, thus making the prognosis less gloomy. But there is a sharp.
difference between the two diseases in their duration. It must not be
forgotten that though in hydatid disease the prognosis must be very
guarded, yet the probably fatal termination is long delayed. The en-
largement of the cyst is very slow, the disease being measured by years.
Barrier's collection of twenty-four cases would put the average dura-
tion at from two to four years, while it at the same time includes single
examples in which the disease was prolonged over periods of fifteen,
twenty, and thirty years. Thus the prognosis must be guarded as to
the duration no less than as to the final issue.
Treatment.-Preventive treatment is a very simple matter. The
entire prophylaxis is included in the single admonition to beware of
the dog. Avoidance of too intimate association with the canine family,
and of gross uncleanliness in personal habit and home surroundings,
insures escape from hydatid disease.
There is no medicinal treatment deserving the slightest degree of
confidence. It has been conceived that Iodide of Potassium and Mer-
cury might have the power to enter the growth, destroy the parasites
and cause absorption. But they have proved useless. The one essen-
tial thing, which must be accomplished by any treatment worthy of in-
dorsement, is the destruction of the echinococci. If they be once de-
prived of all vitality, the system will make safe disposal of the tenant-
less cyst. We fortunately possess ready means for the accomplishment
of this end, for the withdrawal of the contained fluid is all that is
DISEASES OF THE ORGANS OF DIGESTION.
929
necessary to effectually destroy the echinococci which live in it. This
is easily and safely done with the aspirator, its use being free from any
danger of leakage into the peritoneum, or liability to set up purulent
action within the sac by the admission of air. This method is obvi-
ously to be preferred to the use of trocar, canula, and drainage-tube,
which might be called a ruder form of the same procedure, and which
has been used with considerable success in Iceland. Still less desira-
ble is the injection of Iodine, though it has been used in certain in-
stances with favorable result. Up to the present time, experience had
with the aspirator seems clearly to indicate that it is the best possible
weapon against this disease. Murchison collected a table of forty-six
cases in which a very fine trocar was used, practically equivalent to
the aspirator except that it labors under the disadvantage of being
liable to permit the introduction of air. Of these forty-six cases, forty-
three recovered, thirty-five without accident, while suppuration in ten
was met by a free opening, and two of these died. The one remaining
case died from peritonitis.
The only means of cure really contesting the supremacy of the aspi-
rator is electrolysis. At least eight cases of its successful use have
been reported. The positive pole is applied to the surface in the im-
mediate vicinity, and two needles, connected with the negative pole,
are inserted into the cyst. The chemical decomposition thus induced
destroys the structure of the echinococci, effecting their inevitable an-
nihilation. While objection can hardly be raised to the intelligent
use of this method, aspiration is at least as effective, and much simpler.
WAXY LIVER.
Synonyms. - Lardaceous liver, Amyloid degeneration, Colloid
liver, Bacony disease, Morbus cereus, Scrofulous liver.
Definition.—Waxy liver is a rare form of hepatic degeneration in
which the gland becomes greatly enlarged, while its substance ac-
quires a firmness and solidity of texture and a semi-translucent quality
not unlike beeswax-a resemblance which gives the disease its name.
In the first half of the present century it was confounded with fatty
degeneration, of which it was supposed to be a variety; but, though
the coexistence of the two diseases is not unknown, waxy liver is now
recognized as an independent and totally distinct disorder. Neither
is this particular pathological process peculiar to the liver, the hepatic
disease being often accompanied by a degeneration of the spleen and
kidneys identical with that going on in the liver. Chemistry has not
yet been able to tell us what this waxy substance is, but its behavior
in the presence of iodine has suggested that it may be akin to starch.
It must be confessed that the evidence to this effect is slender; and
VOL. I.-59
930
A SYSTEM OF MEDICINE.
yet, it is the feature which has given it the name of amyloid degener-
ation.
Etiology.-Waxy liver depends wholly upon a previously exist-
ing dyscrasia. It is the result of a depraved habit of body. The
minds of both the profession and of the laity are too apt to drift into
the belief that a disease, seemingly cured, is as harmless as no disease
at all. The public should be warned that, at least in the majority of
cases, diseases followed by recovery do yet leave the defences of the
system somewhat the worse therefor. The truth of this assertion finds
emphasis in the causes of waxy degeneration of the liver. One of
these is the cachectic bias attending that protracted suppuration which
waits upon caries and necrosis. Another is the syphilitic poison in
its later stages. The suppuration may not have been supposed to be
capable of carrying with it any possibility of evil beyond the drain
implied in the continued formation of pus; it may have been thought
that the syphilitic poison was entirely eradicated; yet the damage
sustained by the system in both these instances may have been so
much greater than could be guessed that profound organic disease of
a most important organ is the consequence.
Authorities differ as to which of these two causes, long-continued sup-
puration or syphilis, is the more prominent. But there is no question.
that one or the other of them stands behind most cases of waxy liver.
It used to be supposed that mercurial poisoning is capable of producing
this condition, but that idea is now abandoned. Waxy liver is some-
times found in association with tubercular disease, but far less fre-
quently than is the fatty liver. Its production through the agency of
malarial poison is very doubtful. As to sex, the disease is much more
common in males than in females.
Pathology. This condition depends upon a deposit in the liver-
cells and in the walls of the hepatic vessels of a peculiar substance,
giving the liver a somewhat translucent appearance, resembling bees-
wax or Canada balsam, but the exact nature of this deposit has not
been satisfactorily ascertained, the general view being that it is of an
albuminoid nature, being allied to albumen and other protein elements.
The minute arteries and capillaries are almost always first involved,
especially their muscular coat and the cells of their inner coat. The
walls become thickened, the channel is narrowed, and on section the
vessels remain patent, while they assume a compact, translucent, shin-
ing appearance, so that they resemble silvery cords or threads. After
a time the material extends to the cells and intercellular tissues, en-
larging the former and making them more spherical, at the same time
displacing their normal contents, the nucleus being ultimately de-
stroyed. The cells then coalesce, and the whole structure finally pre-
sents the peculiar glistening appearance before mentioned. It is sup-
posed by some that the substance makes its way directly through the
DISEASES OF THE ORGANS OF DIGESTION.
931
walls of the vessels, and afterwards extends into the surrounding tis-
sues. Sometimes the deposit only occurs in isolated, small or large,
spots; but, most frequently, it is more or less uniformly distributed
throughout the entire organ, but in such a manner that the disease is
more marked in some places than in others. The liver is enlarged,
sometimes enormously, but without any irregularity in form or out-
line, the surface being quite smooth, and the margins inclined to be
rounded. The organ has a doughy consistence, and is dense and re-
sisting. On section the surface is homogeneous, and resists the knife
almost like cartilage, and is anæmic and whitish, the section being
smooth, dry, and firm, while little or no stain is communicated to the
blade, as in fatty liver; when the disease. is far advanced, no trace re-
mains of the proper structure of the organ. Waxy liver is frequently
found associated with fatty degeneration and with cirrhotic induration,
where, of course, the condition is modified to correspond with these
diseased states.
The presence of the waxy deposits may be ascertained by the use of
iodine and sulphuric acid. The parts to be examined must be care-
fully cleansed, and a solution of iodine with iodide of potassium in
water, or diluted tincture of iodine, brushed over, when they assume a
mahogany color, quite different from the yellow color of the healthy
tissue. This reaction may be sufficiently characteristic of itself, but,
if to the iodized surface is now added some diluted sulphuric acid, the
affected parts, after some minutes or hours, take on a violet tint, more
rarely bluish. The violet color may be very deep, almost black.
Waxy degeneration is not confined to the liver alone, but involves
the spleen, the kidneys, the lymphatic glands, the intestinal mucous
membrane, and other organs.
Those portions of the liver remaining unaffected by this morbid de-
posit are in a state of congestion, and are softer; or, as has been before
mentioned, they may be involved in fatty or cirrhotic degeneration,
or syphilitic gummata may be mixed up with the amyloid deposits.
The true pathology of waxy degeneration, the modus operandi by
which it is first inaugurated, is, as yet, undetermined. Frerichs*
mentions two modes by which it is possible for the condition to be
established: first, the degeneration may be due to deposition from the
blood; or, second, the waxy substance may be developed in the part
from some albuminous matter previously deposited. Virchow† insists
that the gradual infiltration of the parts in a waxy degeneration is
with a substance brought to them from without. This view he bases
partly on the fact that a whole series of organs is implicated, and that
the morbid process is not confined to a single spot, but affects at the
same time many parts of the body. Although impressed with the
belief that the waxy change is determined by deposition from the
* Op. cit.
+ Cellular Pathology, p. 339.
932
A SYSTEM OF MEDICINE.
blood, neither he nor any other observer has thus far succeeded in
detecting any distinct change in the blood.
Symptomatology.-The symptoms of waxy liver divide them-
selves into two classes, viz., those of hepatic enlargement, and those of
gastro-intestinal disturbance. The enlargement of the liver is a very
gradual process, continued for a long period of time, perhaps for years;
but the size finally attained may be enormous, the gland reaching
dimensions three or four times greater than those of the normal organ,
and apparently monopolizing the entire abdominal cavity. The sur-
face is smooth, and the feeling imparted to the hand is that of great
firmness. The liver might almost be called hard. Beyond a mere
feeling of fulness in the right hypochondrium there is no pain, neither
does manipulation develop any tenderness.
The gastro-intestinal irritation is decided. The stomach does its
work poorly and painfully, there is more or less nausea and vomit-
ing, much gas is generated in the intestines, and the stools become
liquid and lose their natural color. Not unfrequently the same patho-
logical condition exists in the spleen and kidneys. In this event the.
spleen presents enlargement, while profuse, pale urine, of low specific.
gravity, containing albumen, betrays the implication of the kidneys.
Dropsy and jaundice do not occur save as the accidental result of
mechanical pressure.
In considering the symptomatology of this affection, it must be
borne in mind that it is ordinarily a secondary disease, and that the
anæmic symptoms which attend protracted suppuration, or the pecu-
liar manifestations of the specific taint, will be found preceding and
accompanying those symptoms which belong to a waxy liver, the
latter being gradually added to the former.
Diagnosis. Until the disease has progressed far enough to pro-
duce enlargement, diagnosis must of necessity be impossible. When
it reaches that point, it is hardly liable to be confounded with more
than three other hepatic affections, i. e., fatty liver, syphilitic liver,
and cancer. A fatty liver is softer, and is unaccompanied by splenic
and renal disorders; a syphilitic liver is known by its nodules; a can-
cerous liver is tender and painful. These differences, coupled with our
knowledge of the etiology of the disease, free the diagnosis from any
special difficulty.
Prognosis. With no sudden fatality to be provided for, and with
every prospect that the flame will flicker long in its socket before the
lamp of life goes out, the prognosis is still unfavorable in the extreme.
It is not absolutely hopeless, for cases which had not progressed very
far have recovered; but the usual course of events is that of a slowly
advancing chronic malady, with a finally fatal termination, the im-
mediate cause of death being either simple exhaustion or some inter-
current inflammation.
DISEASES OF THE ORGANS OF DIGESTION.
933
Treatment.—An additional reason for the watchful care over
syphilis and for the limiting of protracted suppurations is set before
us in the fact that they threaten the liver with this profound organic.
disease. The therapeutics of syphilis are elsewhere detailed, and
cannot be taken up here. The power of such remedies as Calcarea
carbonica and Silicea in chronic suppurations is universally known;
and just so far as such suppurations may be the cause of waxy liver,
the remedies for the one are the remedies for the other.
As to direct treatment for this disease, there is none known. Cures
have been claimed for Nitric acid and Aurum muriaticum; but they
stand in such close relation to the syphilitic virus that it it is hard to
believe that any favorable result from their use could have been more
than an improvement resulting from a checking of the specific poison.
Tolle causam sums up the possibilities of treatment in this disease at
the present day.
CATARRH OF THE BILE-DUCTS.
Definition.—A catarrhal inflammation of the biliary canals, re-
sulting in tumefaction of the mucous membrane of the ducts, and
usually accompanied with pain, tenderness, distension of the gall-
bladder, and icterus.
Etiology. Catarrhal inflammation of the biliary canals is of not
unfrequent occurrence. The inflammation may involve the mucous
membrane lining the entire biliary tract, or it may be limited to a
small portion of it.
Catarrh of the bile-ducts may arise from a variety of causes. It
usually depends upon the extension of an existing gastro-enteric
catarrh along the ductus choledochus to the cystic duct and to the
branches of the hepatic ducts. Thus, as a sequence of gastro-enteric
catarrh, it results from over-loading the stomach, or from eating indi-
gestible foods; from the indigestion of spoiled and unsuitable food,
or of substances which, owing to some idiosyncrasy, are noxious in
individual cases; also from the use of copious draughts of ice-water or
other cold drinks; exposure to cold or wet, or to drafts while over-
heated, or to sudden changes of temperature.
It may arise from the existence of malaria, or of syphilis, from the
extrusion of gall-stones, from mechanical injuries, and from the irrita-
tion of distomata and other intestinal parasites; also from poisoning
by chemicals and the action of irritating medicinal preparations.
In some instances the inflammation is due to blood-stasis, the result
of enfeebled action of the heart or of valvular insufficiency. Occasion-
ally the disease appears in the form of an epidemic, when it is usually
referable to specific causes. Its prevalence in military encampments,
where there are large aggregations of men, is doubtless due to priva-
934
A SYSTEM OF MEDICINE.
tion and fatigue, together with lack of proper food and hygiene.
In
isolated cases, as well as when the disease is local and endemic, its
existence is usually traceable to some definite source. Indeed, analogy
would teach that catarrhal inflammation of the bile-ducts is produced
by causes closely related to those which produce catarrhal inflamma-
tion in mucous membranes.elsewhere. Depleting diseases, as cholera
and typhus, are important ætiological factors, and Frerichs maintains
that a large majority of cases are traceable to gastro-enteritis. In
thirty-four out of forty-one cases (over 80 per cent.) cited by this
author, there was a preexisting inflammation of the stomach and duo-
denum.
•
Pathology. It is only when life is terminated by some intercur-
rent violent disease that opportunity offers in the early stages of this
affection for noting the pathological conditions attending it.
It is obvious that the appearance of the mucous membrane cannot
be observed in the various stages of hepatic catarrh. Usually the
existence of the catarrh is not suspected until icterus appears; but it
is more than probable that the changes which occur in the mucous
membrane lining the canals are analogous to catarrhal inflammations.
elsewhere.
Post-mortem appearances evidence the swelling of the membrane
and the presence of a tenacious, viscid mucus upon the inflamed sur-
face.
The lumen of the ducts, already diminished by the swollen mem-
brane, is more or less occluded by the mucous secretion which par-
tially or completely arrests the discharge of bile. The retained bile is
mixed with the mucus secreted from the inflamed tissues and with
exfoliated epithelial cells.
When the outlet for the bile, the ductus communis, is obstructed,
the gall-bladder becomes distended, and the tissues of the liver are
tinged with its secretion. Both the weight and size of the organ are
somewhat increased. The lumen of the ductus communis becomes
dilated above the point of obstruction when the stoppage is complete.
Beyond the point of obstruction the mucous membrane is swollen
and oedematous and does not show the yellow tinge, thus giving proof
of the impervious condition of the duct. At the point of obstruction
will be found a plug of tough, grayish-white mucus. Usually these
mucous plugs disappear with the subsidence of the catarrh.
Sometimes, however, a post-mortem examination at a later period
reveals the presence of mucous plugs in the finer hepatic canals where
they form a permanent obstruction to the passage of bile. If the in-
flammation is limited to the gall-bladder and cystic duct, there occurs
but little, or no, enlargement of these organs, save that which may result
from the swelling of their tissues and from the retention of a viscid
mucus secreted from their lining membrane. When the cystic duct is
DISEASES OF THE ORGANS OF DIGESTION.
935
impervious, the gall-bladder contains a tough, ropy, light-colored
mucus or a muco-purulent mass, in which are large numbers of exfoli-
ated epithelial cells from the inflamed mucous membrane. If, on the
other hand, the canal is not obstructed, the biliary secretion finds
its way into the gall-bladder, where it mixes with the products of the
inflamed membrane and constitutes a viscid, greenish or brownish-
yellow mass of considerable consistency.
Symptomatology.-This affection is usually preceded by symp-.
toms of gastro-enteric catarrh. The patient complains of nausea and
bitter taste; the appetite is depraved, the tongue furred, and there are
tenderness and distension of the epigastrium, and other evidences of
gastric irritation, as thirst, fever, and general malaise.
The bowels are usually, but not always, constipated; in cases in
which the digestive irritation is severe, the evacuations may become
diarrhoeic.
The manifestation of these symptoms in severe cases is succeeded
for a few days by unmistakable evidences of hepatic obstruction. No
pathognomonic symptoms betray the existence of catarrhal inflamma-
tion of the hepatic ducts. When the ductus communis alone is the
seat of the catarrh, the discharge of the secreted bile is obstructed, and
the gall-bladder becomes distended. When the inflammation is limited
to the cystic duct, there results little or no distension of the gall-blad-
der; perhaps, a dull pain and general uneasiness in the right hypo-
chondrium, with slight nausea and fever, are all the symptoms
produced.
Indeed, so slight may be the complaint that it may be altogether
overlooked.
When the ductus communis is entirely occluded, the stools become
uniformly grayish or chalk-colored.
If the lumen of the tube is but partly obstructed by the swollen
membrane, bile escapes from time to time, forcing the secreted mucus
before it in its passage; in this event the stools will be more or less
tinged with hepatic secretion.
Jaundice will be found a constant symptom, excepting in those cases
in which the catarrh is limited to the gall-bladder and cystic duct, and
in which the catarrhal condition is so slight as not to obstruct the dis-
charge of bile. Icterus early succeeds the occlusion of the hepatic ca-
nals, varying from two days to as many weeks. Its appearance is most
readily observed on the delicate conjunctiva.
The eyes and skin assume a more or less marked yellowish or orange
tinge, and evidence the non-elimination of bile from the blood.
The urine is loaded with the bile, and the kidneys now become the
chief organs concerned in its elimination. Chemical tests reveal the
presence of the biliary acids in the urine.
Patients become irritable and, while the icterus remains, are fre-
936
A SYSTEM OF MEDICINE.
quently affected with pruritus which is aggravated by heat and the
warmth of the bedclothes. The pulse rate is retarded, and frequently
drops to 55, or even 50, pulsations per minute.
Jaundice manifests itself to a lesser degree when the catarrh is
limited to the finer hepatic tubes, and the stools evidence the elimina-
tion of the hepatic secretion to some degree through the digestive tract.
When icterus is wanting, the other symptoms may be so slight as
scarcely to attract serious attention.
Simple uncomplicated cases of catarrhal inflammation of the he-
patic canals are of very brief duration, usually terminating in from 10.
to 15 days. However, when gastro-enteric catarrh is the occasion of
the inflammation, and when other complications exist, the period of
recovery varies from three to four weeks.
Frerichs cites a case from his experience which was protracted for
several months. When the inflammation is excited by a local irrita-
tion the period of duration is modified by the existence of the exciting
cause. Rarely, suppuration follows the catarrhal inflammation, a se-
quence more liable to result in cases induced by the extrusion of gall-
stones or from mechanical injuries.
Varieties. Of this disease, Froehlick described two distinct types,
distinguished more by their degree of violence than by any patho-
logical or clinical history. The form which prevails in this latitude
occurs usually in isolated or sporadic cases, though sometimes as an
epidemic or endemic disease. In this variety acute yellow atrophy
of the liver very rarely occurs, while during the course of the severer
type, which prevails only in the warmer climates, acute yellow atrophy
of the liver occurs with relative frequency. The severer form of this
affection bears some resemblance to yellow fever, of which malady
it is probably a variety.
Diagnosis. The diagnosis of this affection, after the appearance
of jaundice, is quite readily made. Previous to the occurrence of
icterus, however, it is difficult, if at all possible. As the catarrh of the
bile-ducts results in over four-fifths of the cases from gastro-enteritis,
the prior or concurrent existence of that affection leads to a strong
suspicion of the character of the ailment. Care is necessary in the
diagnosis, in order to exclude other hepatic affections which may
closely simulate catarrhal inflammation of the biliary canals.
The sudden appearance of jaundice in otherwise healthy and vigor-
ous subjects, their previous exemption from diseases of the liver, the
grayish chalk-like color of the stools, their freedom from biliary cal-
culi, and the generally light character of the symptoms point pretty
clearly to the nature of the disease.
Prognosis. In simple uncomplicated cases of catarrhal icterus.
the prognosis is favorable. Sometimes, when repeated attacks of ca-
tarrhal inflammation are induced by the extrusion of gall-stones, or
DISEASES OF THE ORGANS OF DIGESTION.
937
when the obstruction of the bile-ducts is complete and persistent, the
calibre of the canals becomes dilated, and in places sacculated from
pressure of the retained secretion. These dilatations press upon the
adjacent hepatic tissues and cause their absorption, while they re-
main permanently dilated, retaining the secretion, and impeding its
flow.
A doubtful prognosis is warranted in the case of patients affected
with grave lesions of the kidneys.
Where the icterus is severe, and the bile is not eliminated through
the renal tract, cholæmic poisoning may supervene, and a fatal issue.
occur. Continued exposure and irregular habits may precipitate re-
peated attacks, or delay recovery. With relative frequency, long pro-
tracted jaundice is followed by an anæmic condition with much ema-
ciation, a condition arguing a slow or doubtful recovery. Of still
graver import are the severe stinging, shooting pains, occurring in
paroxysms of increasing intensity in protracted cases of catarrhal oc-
clusion of the ducts. These symptoms warrant the suspicion of a
permanent obstruction of the ductus communis. In other cases, re-
sulting from some existing hepatic affection, the prognosis must
necessarily depend upon the nature of the exciting malady.
Treatment.—As catarrhal inflammation of the bile-ducts is essen-
tially an inflammation with, in severe cases, biliary obstruction super-
added, it follows that the remedies chiefly indicated are those which
are useful in like conditions of other mucous membranes. Indeed,
inflammation of the mucous coat of the biliary passages is seldom seen
except in conjunction with corresponding affections of the gastro-in-
testinal tract, and the remedies which are indicated in the latter case
are equally efficient in the former.
The principal remedies are Mercurius sol., Cinchona, Nux vomica,
and Arsenicum.
Mercurius.-Mercurius is indicated more frequently than any other remedy on
account of its special pathogenetic relation to inflammatory conditions of mucous mem-
branes. Fever, tenderness, and swelling of the liver, catarrhal inflammation of the
duodenum; diarrhoea, the stools being somewhat tinged with bile; icteric color of the
skin and conjunctiva, and nocturnal itching, constitute the group of symptoms to which
Mercurius is homœopathic. This remedy is also applicable to cases due to a syphi-
litic origin.
Cinchona.—Cinchona is indicated if the disease occurs during, or after, an at-
tack of malarial fever; or when it follows excessive loss of the fluids of the body, or
depends upon great general debility. The symptoms are nausea, canine hunger, op-
pression of the epigastrium, bitter taste, dryness of the mouth, soft, clay-colored stools,
brown urine, icteric color of the skin, retarded pulse, etc.
Nux vomica.-Nux vomica is particularly indicated in cases of catarrhal in-
flammation of the ducts arising from gastric derangement, from exposure to cold, and
from excesses in eating and drinking; excessive use of iced drinks, etc. Sub-acute
gastritis, extending to the biliary passages, calls especially for the administration of
this remedy.
The symptoms are: sensation of weight in the stomach, tenderness to pressure in the
epigastrium and right hypochondrium, enlargement of the liver; anorexia; white
furred tongue, constipation, hard fæces, brown urine. The dyspeptic symptoms in most
cases clearly indicate the use of this remedy.
938
A SYSTEM OF MEDICINE.
Arsenicum.-Arsenicum is not so frequently indicated as are the preceding
remedies. It is adapted to those cases which are attended with great irritability of the
stomach, fever and the restlessness characteristic of arsenic. The patient complains
of burning pain and thirst, there is nausea and vomiting, tenderness of the abdomen,
diarrhoea of thin, sero-mucous fluid, and accelerated pulse.
Remedies of secondary importance are Chamomilla, Chelidonium,
Pulsatilla, Lachesis, Aconite, and Ignatia.
The diet should be bland and nutritious. All causes which might
increase the irritability of the digestive organs should be sedulously
avoided.
OCCLUSION OF THE PORTAL VEIN.
Synonyms.-Thrombosis of the portal vein, Pylethrombosis, Pyle-
phlebitis.
Definition.-Occlusion of the portal vein (Pylethrombosis) con-
sists, in a large majority of cases, in the formation of thrombi within
the vessel, with or without inflammation of its walls; in rarer instances
occlusion may occur simply as the result of adhesive inflammation
of the walls of the vein (pylephlebitis), without the formation of a clot.
Etiology. The chief ætiological factor in the production of occlu-
sion of the portal vein is the formation of a clot in consequence of
compression of the vein by some force within or without the liver, or
by disease of the liver which diminishes the force of the portal circu-
lation.
The immediate exciting causes are of various kinds. Structural
changes in the portal vein and radicles, diseases of the liver, such as
cirrhosis and cancer, chronic peritonitis, compression of the portal
vein by tumors which have their origin and growth in neighboring
organs, are the principal.
Virchow mentions a case of occlusion which was caused by pressure
from abnormally dilated biliary ducts containing many calculi.
The most common cause of occlusion of the portal vein is chronic
atrophy of the liver. The gradual obliteration of the hepatic branches
of the portal vein which occurs in this disease seriously obstructs the
current of blood, and favors the formation of thrombi.
Pathology. The pathology of obstruction of the portal vein de-
pends largely upon the ætiological relations which exist. Ordinarily
a thrombus is the cause of the occlusion, but obstruction may occur
from compression by tumors in the liver, cirrhosis, or cancerous de-
posits, or from chronic atrophy, the thrombosis only being a necessary
consequence of the otherwise existing obstruction. If a coagulum is
formed in consequence of weakened force of the circulation or, as is
more often the case, from local disturbance of the circulation from the
conditions before mentioned, which may induce destruction of nu-
merous capillaries or constriction of the branches of the portal vein,
DISEASES OF THE ORGANS OF DIGESTION.
939
the wall of the vein at first will be found normal, but it soon be-
comes thickened from adhesive inflammation, infiltrated with serum,
and shows a cloudiness of the mucous coat with an injection of the
fibrous coat. The mass of the thrombus, as a rule, is firmly adherent
to the lining membrane of the vessel, being, in most cases, firm, hard,
and torn with difficulty, rarely soft and friable. Its color is grayish,
red, brown, or blackish, or may be jaundiced. Various changes may
occur in the thrombus itself, and likewise in the venous wall, while
the consecutive derangements in the organs belonging to the portal
system are so prominently developed that the presence of the occlu-
sion is readily inferred. The pressure in the initial radicle of the
portal vein being increased, a free transudation of blood along the in-
testinal mucous membrane occurs, hæmorrhoids form, and a watery
diarrhoea takes place.
As would be the case elsewhere, efforts toward a compensatory cir-
culation are made by the communicating veins, which appear enlarged
on the surface of the abdomen. The obstruction is not always com-
plete, so that an imperfect circulation is maintained, but usually the
vessel is entirely obstructed. Sometimes the thrombus gradually
atrophies, undergoes fatty degeneration, and is partly or entirely ab-
sorbed, while at the same time an inflammatory proliferation of the
wall takes place which terminates in its obliteration. If the liver is
examined after having been the seat of this disease, cicatricial retrac-
tions will be found on its surface, and, within the parenchyma, cor-
responding to these retracted places, there will be found a hard tissue
in which may still be recognized the atrophied branches of the portal
vein. Occasionally these contain remains of the thrombosis, colored
more or less yellow by hæmatin.*
Symptomatology.-Prior to the development of what may be
designated characteristic symptoms of portal occlusion there is usu-
ally observed a series of symptoms indicative of those diseases of the
liver or adjacent organs which are the exciting causes of thrombosis
of the portal vein. The morbid changes and conditions of those
organs which precede and cause occlusion render it difficult, in many
cases, to give a definite clinical history of the disease under considera-
tion.
Nevertheless, there are, in a majority of cases, well-defined symp-
toms which clearly indicate the nature of the morbid condition. There
is a very rapid transudation of serum, so that in a few days the ab-
domen is distended to an enormous size. If the fluid is removed by
paracentesis, it re-accumulates in a day or two. The spleen is en-
larged to three or four times its normal size.
The dejections from the bowels are then sero-mucous and bloody.
* Niemeyer's Practical Medicine, vol. i., page 684.
940
A SYSTEM OF MEDICINE.
Hæmatemesis is sometimes observed. The urine is scanty and high-
colored. The subcutaneous veins of the abdomen are greatly dis-
tended and appear as a sinuous plexus from the thorax to the groins.
The severity and gravity of the symptoms vary according to the
rapid or gradual formation of the thrombus, the completeness or in-
completeness of occlusion, and the degree to which the blood stasis is
relieved by the establishment of a collateral circulation.
The symptoms detailed above are evidently the consequences of
blood stasis, and are the natural sequence of arrest of circulation
through the portal vein. If occlusion is complete, there will neces-
sarily be a rapid transudation and accumulation of fluid in the ab-
dominal cavity and connective tissue. If the abdominal cavity is
emptied, it speedily refills.
Although rapidly developed ascites is the rule, yet, in exceptional
cases, it is absent either because of copious hæmorrhages or of the
establishment of a collateral circulation soon after the formation of the
thrombus.
Enlargement of the spleen, thin, serous, bloody diarrhoea and hæma-
temesis are accounted for on the same grounds, namely, more or less
complete arrest of the portal circulation. Other symptoms which are
commonly present, such as derangements of digestion, atrophy or
hypertrophy of the liver, jaundice, emaciation, debility and general
oedema, are not necessarily associated with portal occlusion, but per-
tain to other diseases of which portal occlusion is the sequel.
Thrombosis of the portal vein does not occasion any local symptoms
unless associated with inflammatory irritation.
In the latter case pain is felt at the seat of the thrombus, whether
situated in the portal vein or in some of its branches.
The liver is sometimes of normal dimensions, though its most fre-
quent condition is that of atrophy. In rare instances it is enlarged.
The variations in size of this organ depend in a large majority of
cases, upon some antecedent affection of which thrombosis of the portal
vein is the sequel.
As a rule, fever and increase of temperature are wanting.
Diagnosis. The diagnosis of portal occlusion is based upon the
occurrence of the series of symptoms already detailed, namely: rapid
accumulation of ascitic fluid, diarrhoea of thin, serous, bloody fluid;
scanty, dark-colored urine, enlargement of the spleen, vomiting of
blood, enormous and tortuous dilation of the subcutaneous veins of
the anterior part of the trunk.
But these symptoms do not enable us to readily determine whether
portal occlusion is caused by adhesive inflammation from thrombosis
or from some other condition.
If the symptoms of occlusion come on with great rapidity, we may
safely assume the existence of pylethrombosis. A previous history of
DISEASES OF THE ORGANS OF DIGESTION.
941
chronic atrophy of the liver renders it very probable that occlusion is
due to the formation of a thrombus.
Prognosis.-Portal occlusion is almost invariably fatal. The mor-
bid conditions existing prior to occlusion are usually of a nature.
dangerous to life, and the gravity of the situation is still farther in-
creased when portal occlusion is superadded. The disease may run
an acute or chronic course. Its duration depends upon the previous
condition of the patient, the nature of the factors concerned in its
production, and the extent to which collateral circulation is estab-
lished.
In the majority of cases the disease runs a brief course. Acute cases
terminate fatally in a few days. Chronic cases, particularly those in
which compensatory circulation is fully established, may last for
months, and, in rare instances, for years, insomuch that the disease.
may be said to have terminated favorably. Instances where life is
prolonged for any considerable period are very seldom observed.
Death commonly ensues in a short time after occlusion is established.
Treatment.-No remedies are curative in portal occlusion. The
indications are to check hæmorrhages and diarrhoea, to support the
patient's strength, and to sustain cardiac action, in the hope that col-
lateral circulation may be established so as to relieve the blood stasis.
If the ascites increases to such an extent as to seriously endanger life,
the fluid must be removed by paracentesis. The operation should,
however, be deferred as long as possible on account of the rapid refil-
ling of the abdominal cavity.
PURULENT INFLAMMATION OF THE PORTAL VEIN.
Definition. A suppurative inflammation of the radicles or trunk
of the portal vein, resulting from suppurative processes in the adjacent
abdominal organs. Purulent infiltration and thickening of the walls.
of the vessel occurs at the seat of inflammatory action. Retardation
of the current of the blood takes place in consequence, and a thrombus
is formed. The thrombus in the next place undergoes purulent soften-
ing, and the vein becomes filled with pus, shreds of fibrin, and a thin,
ichorous fluid. Secondary thrombi are also formed, either extending
backward into a radicle of the portal vein, or forward into one or more
of its hepatic branches. The second thrombus also undergoes the
same degenerative changes. The inner surface of the vessels may
also be the seat of ulceration.
Etiology.-Purulent inflammation of the portal vein, although
occasionally an idiopathic primary disease, is in general a secondary
affection consequent upon an inflammatory suppurative process in
one of the organs from which the radicles of the portal vein derive
942
A SYSTEM OF MEDICINE.
their origin. In rare instances it develops as a primary affection in
consequence of some traumatic lesion of the walls of the vein.
The most common foci of suppurative pylephlebitis are inflamma-
tion and suppuration of the cæcum, the appendix vermiformis, and
the connective tissue surrounding them.
The veins in the vicinity become implicated in the inflammatory
action, are contracted in diameter, and filled with small clots. The
phlebitis gradually advances along the affected veins until it reaches
the trunk of the portal vein and its hepatic branches. Other foci of
purulent inflammation are ulcers of the stomach and small intestines,
abscesses or gangrenous spots in the spleen, and suppurative points in
the mesentery. In all these cases the inflammation extends to some
one of the radicles of the portal vein, and advances along it to the
main trunk.
Still other initial points of suppurative pylephlebitis are in the liver,
the bile-ducts, and Glisson's capsule. In such cases the radicles are
not affected, the inflammation being confined to the portal vein and
its hepatic branches.
Pathology. In this form of inflammation of the portal vein the
morbid changes differ from those of adhesive inflammation occurring
in connection with thrombus. Here the thrombus, instead of becom-
ing atrophied, disintegrates into a purulent fluid, which is, for the
most part, a finely granular detritus, containing only a few roundish
cells which may be either white blood-corpuscles or newly-formed
pus-corpuscles. The whole thrombus rarely breaks down at the same
time. In the trunk of the vein there is often a firm coagulum, while
there is a purulent fluid in the branches and roots. But more fre-
quently, there is no disintegration in the finer branches of the portal
vein, so that the coagula then prevent the disintegrated masses enter-
ing the hepatic vein, and reaching the pulmonary circulation.* Ac-
cording to Frerichs,† the channel of the vein is found to be enlarged
and gaping upon section; the wall of the vein is thickened, softened,
and infiltrated with exudation. The thrombus, in the interior of the
vein, undergoes destruction at an early period; it softens from the
centre into a dirty, grayish-red pulp, and afterwards dissolves more or
less completely into a purulent fluid. The changes in the vein are
most distinctly developed, sometimes at one part of the portal vein,
and sometimes at another, according to the locality where the disease
commences, and its cause; it does not, however, remain circumscribed,
but spreads over extensive tracts of this portion of the venous system.
As a rule, the hepatic branches of the portal are implicated. Their
channel is found blocked up with coagulated blood, fibrinous matter,
or pus, as far as their finest ramifications, or they appear distended
and filled with purulent fluid, so that cavities resembling abscesses
† Op. cit., p. 129.
* Niemeyer, op. cit., p. 684.
DISEASES OF THE ORGANS OF DIGESTION.
943
are seen on section. Sometimes metastatic deposits are developed, as
in other forms of phlebitis, by particles of thrombi being floated by
the blood into the liver; these deposits are found in various stages of
development, from reddish-brown infarctions to yellow cavities of pus.
These metastatic formations rarely extend beyond the liver. Partici-
pation of the roots of the portal vein in the morbid process is still less
constant. Sometimes they are more or less diseased, and filled with
coagulated blood, fibrin, or pus; while in other cases several of the
roots remain exempt, and in others the inflammatory process is seen
to have passed through its various stages. This depends mainly upon
the locality in the vein where the inflammation commenced, and upon
the causes which gave rise to it.
Symptomatology.-The general symptoms of purulent inflam-
mation of the portal vein are pain in the right or left hypochondrium,
epigastrium, or ilio-cæcal region, depending upon the situation of the
inflamed veins; chills, followed by high fever; profuse perspiration,
vomiting, diarrhoea, enlargement of liver and spleen, and jaundice.
After one or two paroxysms resembling intermittent fever, the py-
rexia becomes continuous, broken by chills occurring at irregular in-
tervals. The countenance is haggard and expresses distress, the pulse
becomes small and rapid, the respiration is hurried, the tongue dry
and brown. In a majority of cases there is circumscribed or general.
peritonitis.
Clammy perspiration, great prostration, suppression of urine and, in
some cases, convulsion or coma are present towards the close of the
disease.
Pain is the first, symptom observed. It is first perceived in the epi-
gastrium, if the portal vein is affected; in the right hypochondrium,
if the lesion is in the hepatic branches; in the left hypochondrium, if
the splenic vein is inflamed, and in the right iliac region, if the phlebi-
tis has its origin in the radicles arising in the vicinity of the cæcum.
and appendix vermiformis. If pain is general over the abdomen, co-
incident peritonitis is indicated.
The pain is increased by pressure, and gradually spreads over a
greater area as the disease progresses.
Fever is a constant symptom. It is preceded by a chill of greater
or less duration and severity which is indicative of commencing sup-
puration. The fever at first is of an intermittent type, the paroxysms
of which occur at irregular intervals. The intervals vary from twelve
hours to two or three days.
The chills are followed by great heat and copious perspirations. If
the disease is protracted, it assumes a remittent or continued form.
The temperature during the hot stage rises to 104°, 105°, and in some
cases to 107°.
The pulse ranges from 95 to 130 beats per minute.
944
A SYSTEM OF MEDICINE.
The liver is somewhat enlarged in nearly all cases. The increase in
size is due to the formation of multiple abscesses within its paren-
chyma. If there is no enlargement, it indicates that suppurative in-
flammation is confined to the hepatic vessels. Icterus is present in
about three-fourths of all cases; it is not observed until the earlier
stages of the disease have passed. Compression of the bile-ducts by
the enlarged hepatic vessels or extension of the inflammatory action
to the lining membrane of the ducts has caused biliary obstruction.
The urine, in consequence of retention of bile, exhibits a brown color,
and the fæces are deficient in bile.
Disorders of the digestive system, such as loss of appetite, nausea
and vomiting, watery, mucous, bloody diarrhoea, which finally becomes
colliquative, are conspicuous features of the disease.
Peritonitis generally develops during the course of purulent pyle-
phlebitis. It is circumscribed at first, but gradually extends over the
abdomen. It is attended with great tenderness, tympanitis, tension,
and rigidity of the muscles of the abdomen. A moderate amount of
serum is usually present in the peritoneal cavity.
The liver is increased in size in the majority of cases. The enlarge-
ment is either caused by blood stasis in consequence of obstruction in
the splenic vein, or is due to septic infection of the blood. Sleepless-
ness, delirium, convulsions and coma are not unfrequently present.
They are attributable to septic influences, and generally appear during
the latter stages of the disease.
The duration of purulent inflammation of the portal vein is from
one to six weeks.
The disease is more protracted when it does not assume a septic
character, but one of simple inflammation. Cases of the acute type
generally terminate fatally within two weeks. Those not of an acute
character continue from four to six weeks, and in exceptional cases
to a much longer period. The average duration is two weeks.
Diagnosis. The diagnosis of purulent inflammation of the portal
vein is attended with many difficulties. In a small proportion of
cases the symptoms are so strongly defined that the diagnosis is readily
determined. But in many cases the pre-existent pathological condi-
tions so frequently mask the secondary affection as to make it exceed-
ingly difficult to arrive at a satisfactory conclusion. If, however, a
disease is present, which we know from experience may be followed
by purulent pylephlebitis, and superadded to this are symptoms char-
acteristic of the latter disease, we are justified in assuming its exist-
The principal symptoms, diagnostic of purulent inflammation
of the portal vein, are pain in any of the several locations of the dis-
ease, violent irregular chills, followed by high fever and copious per-
spiration, enlargement of the liver and spleen, icterus, profuse bilious
diarrhoea, emaciation, rapid loss of strength, circumscribed or general
ence.
DISEASES OF THE ORGANS OF DIGESTION.
945
む
​peritonitis. In many cases, however, some of the symptoms above
mentioned are absent.
Purulent pylephlebitis may be mistaken for intermittent fever,
hepatic abscess, catarrhal icterus, and occlusion of the bile-ducts from
gall-stones. Intermittent fever has enlargement of the liver and spleen,
icterus, and successive paroxysms of chill, fever and sweat; but other
symptoms distinctive of disease of the portal vein are absent. Hepatic
abscess has chills, pain, and enlargement of the liver, but lacks the en-
larged spleen, diarrhoea, emaciation and prostration of portal disease.
Occlusion of the bile-ducts has about the same group of symptoms
as hepatic abscess, but in addition has icterus.
Catarrhal jaundice resembles purulent inflammation of the portal
vein in the enlargement and tenderness of the liver, and the icteric
color of the skin and conjunctiva. It is wanting in the chills, fever,
high temperature, diarrhoea, emaciation, and prostration of the latter
disease.
Prognosis. The prognosis is fatal when the main trunk, the larger
radicles, or the hepatic branches are involved. Recovery is possible.
only when some unimportant vessel is involved, and the inflamma-
tion is not complicated with septic infection.
The patient usually dies with symptoms of extreme exhaustion or
merges into a state of coma.
Treatment.—Purulent inflammation of the portal vein is so uni-
formly fatal that but little can be done to modify or arrest the pro-
gress of the disease.
If we fail to prevent the extension of inflammation from the initial
foci of suppurative action into and along the radicles of the portal
vein, any subsequent efforts will be well-nigh hopeless.
The treatment must be chiefly supportive and palliative.
The remedies which are homeopathic to the symptoms are Cin-
chona, Arsenicum, Phosphorus, Silicea, Mercurius sol., and Carbo veg.
G. DISEASES OF THE PANCREAS.*
The pancreas is situated in the upper and back portion of the ab-
dominal cavity, extending transversely from the duodenum on the
right toward the spleen, which it frequently touches, on the left. The
enlarged right extremity, usually termed the head, is in close relation
to, and grasped by, the concave border of the duodenum. The body
* This article is, in part, an abstract of the report of the Homeopathic Medical So-
ciety of Philadelphia County, presented to the Homeopathic Medical Society of the
State of Pennsylvania, and published in the Transactions (1880) of the Pennsylvania
State Society. This very able report was prepared by a committee consisting of Drs.
A. R. Thomas, J. C. Morgan, A. Korndoerffer, and E. A. Farrington.
VOL. I.-60
946
A SYSTEM OF MEDICINE.
of the gland rests upon the superior mesenteric artery and vein, ex-
tends transversely, tapers, and ends in the left small extremity or tail.
Its length varies from six to eight inches, and its weight from two to
four ounces. It is held in position by its close attachment to the
duodenum on the right, by its adhesions to the blood vessels behind,
and by the ascending layer of the transverse mesocolon which passes
in front.
In structure, the pancreas is a compound racemose or conglomerate
gland, resembling strongly the salivary glands, though looser and
softer in texture. It is made up of numerous small lobules, united
by loose connective tissue, these being composed of microscopic vesi-
cles varying from the to of a line in diameter.
2
400
The excretory ducts, originating in some obscure manner among
the cells, unite, forming large branches ending in the main excretory
duct, which has been named, from its discoverer, the duct of Wirsung.
The canal of Wirsung extends through the whole length of the
gland nearer the lower border, increasing gradually in size, until, upon
reaching the duodenum, it acquires the size of a quill. Uniting with
the main duct a supplementary duct is not unfrequently found,
springing either from some portion of the head, or from that portion
projecting from the posterior part of the body known as the lesser
pancreas; this unites with the main duct, which, upon reaching the
duodenum, joins the ductus communis choledochus, and terminates
usually by a single orifice at the apex of a papilla of the mucous
membrane.
The position of the pancreas may be indicated upon the surface of
the abdomen by a line drawn transversely at a point about midway
between the umbilicus and the lower end of the ensiform process of
the sternum. To reach the gland in post-mortem examination, the
great omentum should be torn from the lower border of the stomach,
when, by lifting the latter and dragging down the transverse colon, the
pancreas may be seen in the back part of the cavity of the lesser
omentum.
The secretion of the pancreas consists of a clear, colorless fluid,
closely resembling saliva, containing, however, a very much larger
amount of albumen and casein than are found in the saliva; the pan-
creatic juice, unlike the secretion of the salivary glands, contains no
sulpho-cyanide of potassium. The function of the pancreatic juice is
two-fold; it completes the process of converting the amylaceous and
starchy foods into sugar, and it emulsifies fat, thus rendering it fit for
absorption by the lacteals.
Owing to the anatomical relations of the pancreas, and to disturb-
ances in other organs almost always present when we have reason to
suspect the existence of pancreatic disease, palpation and percussion
are of comparatively little value here for diagnostic purposes. It is
DISEASES OF THE ORGANS OF DIGESTION.
947
at times possible to detect an enlarged pancreas by placing the patient
upon the back, and producing relaxation of the abdominal covering
by having the legs flexed upon the abdomen; a more or less well-
defined, somewhat oblong tumor may be felt, lying transversely below
the stomach, a little to the left of the median line. Dr. Aug. Korn-
dorffer employs a method of physical examination which he terms.
"impulsion" and describes as follows:
"In order to examine the pancreas by impulsion, the patient should,
if possible, stand upright, thus keeping the abdominal muscles more
or less tense. Let the examiner, sitting to the right of the patient,
place his left hand over the tenth and eleventh dorsal vertebræ, his
right hand at the upper portion of the hypogastric region. Then, by
a strong and sudden push, made with the right hand upwards and
backwards, an impulse is communicated through the abdomen to the
pancreas which, if the pancreas be unduly sensitive, will elicit an
aching or bruised, sore feeling. The patient may at first find some
difficulty in locating this new sensation, both on account of its more
or less indefinite character, as well as from its being experienced at a
point different from that to which the usual pain had been referred."
The pancreas is subject to inflammation of various degrees of in-
tensity, resulting in adhesion to adjoining organs and in the various
changes of structure which are the natural result of inflammation ;
this inflammation may be acute, subacute, or chronic, and at times.
takes place by metastasis from some other organ. The gland may
become the seat of fatty or amyloid degeneration, of cancer, concre-
tions, cysts, various morbid growths, hemorrhage, and certain func-
tional disturbances not yet understood; hypertrophy and atrophy
occur, and anomalies are noted which, however, are of no practical
interest. As yet, the morbid states of this organ are little understood,
and their discussion here will be brief.
Acute Pancreatitis.-Acute inflammation of the pancreas may
be primary or secondary. It may occur ab initio, or by extension, or
by metastasis, or it may form part of a more general affection, as the
malarial, typhoid, and other fevers, in which the liver, spleen, kid-
neys, and other tissues are more or less concerned in a like process.
In addition may be named the catarrhal inflammation, the hæmor-
rhagic, the purulent, the simply metastatic, and the pyæmic; six forms
being defined, probably referable to two or three original types.
The first is the catarrhal; it usually begins with duodenitis.
The second is called parenchymatous degeneration, but it is strictly
an inflammation in which the gland-cells are distinctly concerned,
these, on section of the reddened and enlarged gland, being found so
distended and opaque as to defy definition under the microscope.
The tendency is to acute fatty degeneration, the cell-protoplasm being
found, even early, granular in appearance, obscuring their other con-
948
A SYSTEM OF MEDICINE.
tents. However, by adding the solvents, acetic acid, then solution of
potash, this granulation is cleared up, and the inflammatory multi-
plication of the nuclei is made visible; from two to five of these
are found in each affected cell, with their nucleoli. The recogni-
tion of this acute parenchymatous pancreatitis is almost complete
with the mere presence of an acute infectious disease (i. e., a “spe-
cific fever"), and with swelling of the liver and spleen, affording
evidence of a like gland-cell inflammation in these organs, and, in
extreme cases, albuminuria, consequent on a similar process in the
gland-cells of the kidney. Parenchymatous pancreatitis is the ordi-
nary associate of these. The same is also found in the muscular sys-
tem, in such cases. Frerichs, in discussing acute yellow atrophy of
the liver, advocates the similarity of these several processes, and con-
siders that typhoid fever, in particular, presents this condition in a
moderate form. Poisoning by arsenic or phosphorus produces a sim-
ilar cell-change, as well as many like symptoms during life. Pyæmia
causes a like alteration, added to its deposits of puruloid matter.
The jaundice often attending these various diseases may possibly,
according to Friedreich, arise from compression of the gall-duct by
the swelled head of the pancreas, and not alone by catarrhal tumefac-
tion of the duct itself.
The third form of acute pancreatitis is the hæmorrhagic, which must
not be confounded with pancreatic apoplexy, to which reference will
be made hereafter.
This form is of rare occurrence. In a case quoted by Friedreich
(Ziemssen's Cyclopædia, vol. viii., p. 596), the patient, a previously
healthy man, was taken with violent cardialgia, which steadily in-
creased; vomiting came on, with frequent evacuation of bile-like
matter; constipation; great aggravation of pain by pressure on the
epigastrium; high fever; then deathly pallor, great restlessness, and
frequent faintings, collapse, death. The pancreas was found trebled in
size, surrounded by extravasated blood, and with extravasation in the
acini of the gland. In another case, occurring in a young man addicted
to the excessive use of alcohol and tobacco, the symptoms were similar
to the one cited, but the fever was slight; the pain was at first like
colic in the upper abdomen, then a continuous, agonizing burning,
with great anxiety, nausea and vomiting without relief. Then the
upper abdomen became distended and hot, with shooting or drawing
pains, violent, continuous, and greatest along the greater curvature of
the stomach, shooting to the duodenum, spleen, navel, and upward
toward the scapula; persistent constipation; constant thirst; moist,
thickly coated tongue, with only a little viscid saliva; belching; head-
ache; vertigo; cold sweat; pulse 75. Collapse was imminent, and
finally, after a few days, the extremities becoming very cold, collapse
took place and death ensued.
DISEASES OF THE ORGANS OF DIGESTION.
949
The autopsy showed the head of the pancreas dark red, livid, and
in parts infiltrated with blood. The mucous membrane of Wirsung's
duct was darkly reddened, and the head of the gland was studded
with small yellowish and finely granular exudations.
The symptoms of purulent pancreatitis, judging from two cases also
furnished by Friedreich, closely resemble those of the hæmorrhagic
form. In the first case, post-mortem examination showed a large
abscess involving the pancreas situated behind the stomach, with three
perforations, as large as peas, in its posterior wall; the cavity extended
backwards to the spine, and to the pylorus and spleen. The pancreas
was grayish, discolored, flaccid, and extensively infiltrated with pus.
The other patient, a strong man of forty years, was suddenly seized
with symptoms of acute peritonitis. The autopsy revealed general
peritonitis, greatest above, with sero-purulent exudation, matting the
organs together. The pancreas was the seat of a multitude of little
abscesses, many of which had burst into the peritoneal cavity, thus
developing the fatal peritonitis. Atelectasis of both lower pulmonary
lobes had also supervened.
The metastatic form of pancreatitis is the counterpart of the same
process occurring in mumps, affecting the testes or other parts. Fried-
reich mentions the case of a syphilitic woman, sick with parotitis,
who, after having been thoroughly salivated, was taken with symp-
toms of acute pancreatitis, and copious diarrhoea. This also ceased,
and suddenly, at night, both parotids swelled, without salivation. She
died in collapse. The pancreas was found swollen, reddened, very
full of blood, and indurated; both parotids were inflamed.
When symptoms of pancreatitis occur during an attack of puerperal
fever or of pyæmia, it is held that the gland partakes of the general
pyæmic condition, and in such cases we speak of the pyæmic variety
of pancreatitis.
Diagnosis. —Amongst the most important symptoms of acute pri-
mary pancreatitis, mention must be made of colicky, or deep-seated
dull pains, commencing in the epigastrium, and shooting either to-
wards the shoulder or towards the spine. This pain may in a short
time become very intense, and may be accompanied by great restless-
ness, præcordial anxiety, dyspnoea, tendency to faint, nausea, eruc-
tations and vomiting of a thin, bile-stained fluid, which affords no
relief, or the vomit may be of a clear, or greenish, viscid fluid. Thirst
is often present, though the tongue is moist. The moisture of the
tongue is usually marked in pancreatic disease, standing in contrast
with the dry tongue of inflammatory affections of other abdominal
organs. The bowels are usually constipated; distension of the abdo-
men is not uncommon, and, when existing, interferes seriously with
physical examination by palpation or percussion, but not to so great
a degree with impulsion.
950
A SYSTEM OF MEDICINE.
Slight pyrexia generally accompanies this condition.
In unfavorable cases the symptoms attain their greatest intensity
within a few days; the pulse then becomes small, suppressed, and
irregular, the extremities cold, and the features hippocratic, death
taking place in acute collapse. In case the inflammatory process goes.
on to suppuration, we have rigors alternating with flushes of heat.
If the peritoneum becomes involved, symptoms of local or general
peritonitis supervene. Acute pancreatitis must be carefully differen-
tiated from acute inflammation of the adjacent abdominal organs.
From acute gastritis it may be distinguished by the fact that this
affection is generally superinduced by corrosive or irritating sub-
stances, especially the mineral and acrid poisons, as arsenic, tartar
emetic, mustard, ipecacuanha, etc., or from irritative substances taken
as food, such as decomposing meat, vegetables, or shell-fish, or from
very cold or very hot food or drink; in addition to which we find
wanting the more characteristic vomiting of all food and drink, to-
gether with the aversion to eating so common in acute gastritis.
Acute hepatitis is characterized by more or less pain in the liver,
which is aggravated by pressure as well as by deep inspiration and
from cough. The yellow tinge of the conjunctiva, or the more fully
developed jaundice, though so characteristic of hepatitis, may also
be found in acute pancreatitis when it is accompanied by much
swelling of the gland, in cases where the ductus choledochus passes
partially or mainly through the head of the pancreas. Swelling of
the head of the pancreas, in such cases, causes closure of the duct,
thus obstructing the flow of bile. Here, however, the location of
the pain, and especially the marked sensitiveness of the liver on per-
cussion or palpation in cases of hepatitis, will usually serve to pre-
vent error.
From hepatic colic it may be distinguished by the difference in
the starting-point and location of the pains; in hepatic colic the
pain is referred to the gall-bladder and from thence radiates to the
chest, shoulder, and other parts; again, in hepatic colic, save when of
short duration, we have jaundice; this, though possible, is not com-
mon in acute pancreatitis. The previous history will also throw light
on the nature of the case.
The diagnosis of secondary pancreatitis is a matter of conjecture, even
Friedreich frankly acknowledging the impossibility of making it.
Diagnosis of Chronic Pancreatitis.-Owing to the fact that
this form of pancreatitis occurs as a part of a larger pathological group,
usually involving profound and extensive changes in neighboring
viscera, its diagnosis is associated with very great difficulty. The
epigastric pain, disturbances of digestion, vomiting, jaundice, dropsical
effusions in the legs and in other parts of the body, are of no great
diagnostic value; the presence of fatty stools, melituria, and the exist
DISEASES OF THE ORGANS OF DIGESTION.
951
ence of a tumor in the epigastric region, probably limit the diagnosis
to the pancreas, and the exclusion of cancer, from the absence of con-
stitutional and other symptoms indicative of such a condition, would
make the diagnosis of chronic pancreatitis one possibly correct.
Subacute pancreatitis is merely a transition from the acute into
the chronic state.
Chronic pancreatitis may be subdivided into the catarrhal, the
parenchymatous, and the interstitial.
In the parenchymatous form the secreting gland-cells swell, their
nuclei multiply by division, the cells develop, and the gland enlarges,
subject to later degenerative metamorphoses. It is not unusual, in
this form, to find interstitial inflammation existing in the later stages
of the disease.
Chronic inflammation of the interstitial connective tissue framework of
this gland, as in other organs, usually occurs more or less at the ex-
pense of the parenchyma, sometimes even to its destruction, by en-
croachment, by pressure, by starvation of blood-supply, and thus by
simple atrophy or by fatty or cheesy degeneration; the organ, at first
enlarged and indurated, becomes irregularly contracted, in other
words, cirrhosed. Microscopically, the connective-tissue corpuscles
multiply by division, their fibrous processes extend and increase, the
whole framework thereby thickens; the young and succulent tissue
thus formed becomes more solid, and gradually contracts; the gland-
cells perish by fatty change; the organ becomes nodulated and indu-
rated, until the cirrhosis is complete, sometimes causing the appear-
ance, and even the erroneous appellation, of steatoma or of scirrhus.
Glandular atrophy is the proper designation of extreme states of this
kind. Such a pancreas has not unfrequently been found after death
from diabetes mellitus.
The symptoms of parenchymatous pancreatitis ought to present a
scanty, condensed, but inert, secretion, and complaints during late, or
duodenal, digestion, modified, or not, by the abundance or deficiency
of bile, and benefited by the use of prepared pancreatine. The symp-
toms of chronic interstitial pancreatitis should suggest a somewhat
copious, but gradually weakening, secretion, with slowly progressive
dyspepsia, looseness of the bowels some time after eating, and fatty
stools.
In both cases fatty matters should be found in the stools, increas-
ing as time advances; and diabetes mellitus is always to be suspected
if the symptoms indicate pancreatic disease of any duration..
Partial or limited cirrhosis may occur in the head of the pancreas,
less often in the body, rarely in the tail.
The following symptoms, occurring in the living, suggest the exist-
ence of chronic pancreatitis: The previous abuse of alcohol, tobacco,
mercury, quinia; old and maltreated malarial, or other, fever, followed
[
952
A SYSTEM OF MEDICINE.
by fatty stools, oily or saccharine urine, with deep-seated, dorsal-
epigastric pain; neuralgia; a deep-seated, transverse swelling, tender
on pressure; subsequent implication of the biliary duct, or vena porta,
or vena cava, with obstruction of either, and consequent jaundice or
dropsy of the abdomen or legs; or disease of the pylorus or duodenum,
with progressive regurgitation or vomiting of food (blood and pus,
if suppurative). These symptoms, appearing in such order, may well
mean primary inflammatory pancreatic disease; a reverse order would
imply secondary extension from other inflamed organs, as the liver or
intestine.
Fatty Degeneration.-The earliest microscopical appearance is
granulation of the cell-protoplasm. This is due to the decomposition
of particles of the albuminous matter, forming a microscopic oil-
globule. These granules enlarge, become more plainly oily, then
coalesce, hiding the nucleus. Lastly, the cell perishes, and only fatty
detritus remains, sometimes filling, and even distending, the ducts.
The acinous contour is retained until these contents are absorbed
or discharged, when atrophy gradually appears. If interstitial new
growth, from chronic inflammation, be also present, a contracted,
tough, indurated body results; if not, it appears soft, flaccid, and
wasted.
One of the important features of fatty degeneration, here or else-
where, is the frequent involvement of the walls of the blood vessels,
in which case serious hæmorrhages are liable to occur.
Amyloid Pancreas.-This condition is only a fractional part of a
general tissue degeneration which finds its first location in the walls
of the smaller arteries, thence extending to the cellular elements of
organs, and finally involving all the tissues in its vicinity, forming a
waxy, or lardaceous, firm mass; hence, the synonyms .waxy or lar-
daceous degeneration. The term "albuminoid " is sometimes used,
meaning that the abnormal matter is nitrogenous.
The liver, spleen, and kidneys are quite often simultaneously af
fected, are greatly and progressively enlarged, become firm, and lose.
their function. The intestinal blood vessels and other tissues partici-
pate, causing a form of ulceration and chronic diarrhoea.
Its causes are found in all debilitating diseases, as bone-caries,
phthisis, and, above all, syphilis. It is more common, at least in its
earlier form, than is usually believed; it is only revealed by micro-
scopic observation or by the iodine test.
By interference with adjacent nutrition, fatty degeneration becomes.
an occasional concomitant. Friedreich describes a case of phthisis
with amyloid degeneration of the pancreatic vessels and fatty degen-
eration of the gland-cells.
Pancreatic Hæmorrhage (Pancreatic Apoplexy).-Bleeding in
the pancreas depends upon various causes, more frequently organic
DISEASES OF THE ORGANS OF DIGESTION.
953
disease of the heart, lungs, liver, causing in the pancreas a series of
inflammatory changes leading to fatty degeneration, breaking down
of the walls of the blood vessels, and bleeding. Klebs affirms that
diffuse hæmorrhage sometimes occurs quite independently of these,
the pancreas being found red, and the acini gray or pigmented. Usu-
ally, the results of hæmorrhage are fatal. If not immediately fatal,
we may get a secondary peritonitis, with sloughing, or these may de-
velop a pulsating tumor, with well-marked constitutional disturbances,
and a tendency to an exacerbation of all the symptoms, likely to result
in death. Stoerk mentions such a case in which the pancreas was
converted into a blood-cyst weighing thirteen pounds. Sometimes
hæmorrhagic spots are scattered through inflammatory or new-formed
connective tissue, degenerating into oval pigmented masses, or cyst-
like "spaces containing a colored serosity, and surrounded by thick-
ened, irregular, rust-colored walls;" secondly, ordinary retention-cysts,
with hæmorrhagic contents. Diseases of venous obstruction (of heart,
lungs, etc.) are connected with the former, obstruction of Wirsung's
duct with the latter. The greater hæmorrhages seem more closely
identified with diseases of the solar plexus. The blood may find its
way into the duodenum, giving rise to hæmatemesis or to bloody
stools.
Cancer of the Pancreas. This affection is found more fre-
quently in men than in women, occurs very rarely before the fortieth
year, and is probably, to a large extent, due to heredity. The earliest
symptoms experienced are a sense of discomfort in the upper abdom-
inal region and derangement of digestion. Of thirty-seven cases men-
tioned by Da Costa, dyspeptic symptoms existed in twenty-five; vom-
iting, from concomitant gastric disease, in twenty-two; whilst twenty-
four had jaundice; fifteen, dropsy; nineteen, obstructed bowels; and
fifteen, alternate constipation and diarrhoea.
The pain is neuralgic, involving the branches of the coeliac plexus;
deep in the epigastrium, sometimes going crosswise, or running to
either hypochondrium, usually the right, or to the shoulder, or the
back, or sacrum, or over the whole abdomen, often aggravated by
the upright posture, better by forward flexion.
The presence of a tumor is not readily discovered unless it has
attained considerable size, and even then the utmost care and skill
must be exercised not to confound it with cancer of the omentum,
liver, or stomach. Symptoms of the cancerous cachexia, character-
istic glandular enlargements, etc., establish the existence of cancerous.
trouble, and the presence of fatty stools and of renal complications,
with sugar in the urine, point to the pancreas as the seat of the disease.
The pressure of the tumor upon adjoining organs gives rise to a variety
of symptoms, chiefly due to obstruction, which need not be enumer
ated; or the cancer, if primary in the pancreas, may attach to other
954
A SYSTEM OF MEDICINE.
organs, or, ulcerating, may perforate adjacent organs or structures,
making its way into the abdomen, chest, attacking the pylorus, duo-
denum, gall-bladder, liver, kidneys, even vertebræ, or perforating the
intestine or some bloodvessel.
The diagnosis of cancer of the pancreas partakes of the same air of
uncertainty which hangs about this entire group of affections. Occur-
ring, as it does, in connection with similar diseases of other organs,
and by the pressure upon adjoining structures giving rise to a series.
of symptoms well calculated to mislead, the diagnosis depends largely
upon the history of the case and upon the presence of the cancerous
cachexia.
"Probably one of the most important symptoms of this disease is
the intense and persistent pain deep in the epigastrium. This pain
is of marked neuralgic type, has times of remission, often coming on
in paroxysms which may continue from a few minutes to even days ;
it can scarcely be said to intermit, as in most cases a constant, though
less severe, pain is experienced between the paroxysms. This latter
condition is not met to the same degree in chronic pancreatitis, where,
though the pains may be equally severe, there are times of entire ces-
sation.
(6
'The pain in cancer may be either local, confined to a spot deep in
the epigastrium, or it may extend across the epigastrium to either one
or the other hypochondrium, most frequently to the right; or it may
shoot toward the back, sacrum or shoulder. At other times the pain
may spread from the epigastric region through the entire abdomen.
Position exerts considerable influence in modifying the pain, it being
decidedly aggravated in the upright position, and markedly relieved
when the abdominal muscles are flexed. An appreciable tumor
affords important evidence in this affection, though, unfortunately,
owing to the position of the pancreas, this in most cases does not
exist; the head of the pancreas, being the part most frequently at-
tacked, lying beneath the liver, is beyond the reach of both palpation
and percussion. Even in the more favorable cases it will be necessary
to examine the patient when the stomach is empty, care being taken
that the bowels have been thoroughly evacuated of all solid fæcal
matter. The abdominal muscles must be thoroughly relaxed, the
patient either lying on the back with the knees well drawn up, or
placed in the knee-elbow position. In some cases it will be necessary
to employ an anaesthetic for the purpose of gaining thorough relaxa-
tion of the abdominal muscles. Even when we have discovered such
tumor, unless we can exclude cancer of the stomach, liver or omen-
tum, we are not in a position to give a positive diagnosis. Finally, if
the patient be advanced in years, and of marked cachectic habit, suf-
fers from a continuous pain in the epigastrium, and a tumor be found
located deep in the same region, and in addition, we have ground to
DISEASES OF THE ORGANS OF DIGESTION.
955
exclude primary disease of the neighboring abdominal organs, we
have fair reasons on which to diagnose cancer and to locate the dis-
ease in the pancreas. The presence of fatty stools, or melituria, adds
largely to the certainty. The size, nodulation and density of the
growth would distinguish it from chronic enlargement, as would the
density and nodulation from cystic degeneration.”
Sarcoma of the pancreas cannot be distinguished from cancer, as
the symptoms and conditions accompanying the one affection are
likewise found with the other.
Tubercle of the pancreas is happily a most rare affection and, it
may safely be asserted, occurs almost always in connection with tu-
bercular affection in the lung or intestine. Sarcoma may be placed
in the same category. Both conditions lack wholly in clinical im-
portance.
Concretions in the Pancreas. These occur in the duct and its
branches, even to the smallest, and are of two kinds, viz.: proteina-
ceous and calcareous. Incrustations may form in the duct, but com-
monly they assume the form of stones, of dimensions varying from
the microscopic to the size of a walnut. Often they are multiple, even
numerous.
1
Virchow described the proteinaceous concretions as microscopic,
solid, and insoluble; they were found in a syphilitic woman. The
calcareous forms consist of carbonate and phosphate of lime, the
larger sometimes showing cavities containing smaller calculi, or
chalky powder, with milk-like fluid, as if included by accumulated
surrounding incrustations. Sometimes cancer coexists, either in the
gland itself or in neighboring organs, as the stomach.
The causes of such concretions are similar to those elsewhere ob-
served: first, the nature of the food and drink used must be taken
into account; second, the presence of particles capable of becoming
the nuclei or nidus of deposit; e. g., the solidified, glassy, proteinaceous,
microscopic concretions of Virchow; or blood, or catarrhal matter
proceeding from inflammatory exudation, may become nuclei for
large calculi; third, inflammatory deposits, containing lime-salts,
which remain after absorption of the organic matter; fourth, chemical
precipitation of the inorganic matters, especially lime; of the pancre-
atic secretions upon and into the mucous epithelium of the ducts, in
which case the carbonic acid of the blood, which is believed to hold
them, normally, in solution, probably escapes, perhaps aided by the
superior affinity for lime of the phosphoric acid of associated alka-
line phosphates, thus forming phosphate of lime; or, again, the pan-
creas being known as the one organ which can and does decompose
fats into glycerine and fatty acids, it may be that these nascent acids.
form insoluble fat-salts of lime, sometimes to be further oxidized
and changed to its equally insoluble carbonate; fifth, in diseases of
956
A SYSTEM OF MEDICINE.
bones metastases of lime-salts to various parts of the body are com-
mon, and the pancreatic secretion may be affected thus, and concre-
tions form therein; sixth, constitutional vices may determine a
degenerative nutrition, simultaneously existing in various organs,
including the pancreas. Thus, syphilis may involve the aorta in
atheroma, ending in calcification, along with pancreatic disease, prob-
ably of similar nature and origin. Such a case occurred in the clinic
of Prof. Wm. Pepper, of Philadelphia, causing jaundice, with diabetes.
mellitus, and albuminuria, and death, with symptoms of blood-poi-
soning. After death, the common gall-duct and pancreatic duct were
both found impervious, owing to pancreatic concretion; and both the
gall-bladder and the duct of Wirsung were so distended as to form
large fluctuating tumors, felt during life.
The results of pancreatic concretions are suggested by the symptoms
of this case.
We may have obstruction of one or both of the com-
panion ducts; the loss of the functions of the affected gland; forma-
tion of retention-cysts in the course of the duct of Wirsung, which
may reach even to the size of a child's head, forming a fluctuating
tumor in the epigastrium; distension of the gall-bladder; jaundice;
diabetes mellitus, to which allusion has been made as a frequent
attendant on pancreatic diseases; pressure on surrounding parts, with
possible injury; atrophy and destruction of the gland-tissue itself.
Inflammation of the pancreas may result; we have fatty stools and
lientery from failure of the pancreatic secretion and digestion, with
or without the failure of the assisting emulsifier, the bile; aneurism
of the aorta, if connected with solid growth and pressure above the
pancreas, with contraction of the same below, caused by pressure, and
causing circulatory disturbances, etc., in the dependent parts; pres-
sure on the vena cava, or vena porta, with obstruction, dropsy etc.;
pressure on, and irritation of, the solar plexus of nerves, with vaso-
motor, cardiac, and other troubles; or, we may have, from extension
of inflammation, the involvement of the plexus, the supra-renal cap-
sules, etc., as in Addison's disease.
as
Pancreatic concretions are sometimes associated with other lesions,
as cancer, either of the gland itself or of some neighboring organ,
the stomach, or with aortic calcification.
THE THERAPEUTICS OF THE DISEASES OF THE PANCREAS.
The treatment of the diseases of the pancreas can not be satisfactory
so long as our knowledge of their pathology is limited to the evidence.
of rare and very unsatisfactory examinations of the organ after death,
and so long as we are not able to recognize them in the living, unless
exceptionally well pronounced. It is true, the totality of symptoms
affords to the physician the greatest help in directing treatment, even
DISEASES OF THE ORGANS OF DIGESTION.
957
though he be ignorant of the nature of the very disease he is seeking to
remove; and quite likely, many cases of pancreatic disease, erroneously
placed among gastric, and other, affections, are cured by the exhibition
of remedies thus selected when the prescriber is in blissful ignorance
of the very existence of the foe he met and conquered. Yet, such
blind dependence upon symptoms alone cannot be satisfactory to the
thinking practitioner, and to such this class of diseases offers rare
opportunity for profitable study. Under the circumstances, then, we
must content ourselves with a comparison of symptoms, also bearing
in mind the close similarity between the salivary glands and the pan-
creas, and the probability that a class of remedies capable of exerting
a marked effect upon the former will probably not prove without value
in the treatment of the latter.
Iris versicolor.-This useful remedy exerts a positive effect upon the pan-
creas, as shown by the experiments made upon animals by Dr. Burt, one of the
provers of Iris. Having killed several cats with the tincture of Iris, Dr. Burt found
in them a highly congested condition of the pancreas. A portion of one pancreas was
subjected to a critical microscopical examination, which proved the presence of intense
congestion of the minute vessels, and even a rupture, and also extravasation of blood
into the tissues of the gland." (E. M. Hale.)
Dr. E A. Farrington points out the following symptoms: Burning distress in the re-
gion of the pancreas; vomiting of a sweetish water; saliva has a greasy taste; green,
watery diarrhoea, worse from 2 to 3 A.M.; offensive flatus, smelling like copper. Diar-
rhœa contains undigested fat; bilious vomiting; sick headaches return periodically
every week; dull throbbing or shooting over one eye, usually over the right, with
dim vision, nausea and vomiting.
It is evident that the remedy must be of positive value in the treatment of (acute)
pancreatitis.
((
Baryta muriatica.—Frank (Frank's Magazine, vol. ii., p. 644) relates the
following case: A young man, about thirty years old, has been subject, for a long
time, several times each day, and also in the night, to such violent attacks of distress.
and suffocative spells, that he was obliged to roll about on the floor, after the fashion of
an epileptic, save that he retained consciousness. He was compelled to sit absolutely
straight, his head bent forward, a constant stream of saliva running out of his mouth.
This flow of mucus occurred with even slight paroxysms; it seemed most like saliva
of which a soup-plateful would run from the mouth. In the left side, a trifle below
the stomach, a hard substance could be detected, and the patient affirmed that he has
always been conscious that his paroxysms came from that spot. After attempting in
vain to secure relief by a large number of remedies, he was given Baryta muriatica
pura, and he was cured in two months, having used three drachms; the hardness,
the flow of mucus or saliva, and the tightness across the chest had all disappeared.”
Symptoms recorded by provers show general constitutional and gastric disturbances
which point to Baryta mur. as a remedy which, in the earlier stages of pancreatic
affection, might prove useful. There is swelling of the salivary glands; profuse sali-
vation; bad taste in the mouth, even the food tastes badly; coated tongue; loss of
appetite; nausea; retching; incessant, tormenting, ineffectual retching; inclination
to vomiting; violent vomiting of slimy, watery fluid; vomiting of small portions of a
nauseous looking and tasting substance, for six hours; troubles with the stomach;
pressure in the stomach; continual pain in the abdomen; diarrhea; profuse diarrhea,
without pain in the bowels; liquid stool; stool coated with mucus.
The experiments upon animals made by Orfila and Gmelin in their general drift
correspond with the above symptoms. The remedy should prove useful in persons of
a scrofulous habit, with glandular enlargements and itching-burning of the skin.
Iodum.-Rademacher claimed to have observed an epidemic of pancreatitis, con-
tinuing for a year; and a study of the cases described by him establishes pretty con-
clusively the correctness of his diagnosis. He employed tablespoonful-doses, every
hour, of a solution of thirty drops of the tincture of iodine in eight ounces of water,
958
A SYSTEM OF MEDICINE.
receiving uniformly rapid curative action from the remedy; he lays particular stress
upon the turbid condition of the urine.
Iodine, in its action upon the salivary glands, causes increased secretion of watery
saliva; it has also violent copious vomiting of a watery or sour substance; diarrhoea of
copious, soft, watery, foamy stools, and violent pain in the epigastric region and back;
great emaciation; voracious appetite, but grows thin in spite of eating heartily; soapy
taste in mouth; pasty evacuations from the bowels; whitish stools, softer than usual.
Reil (Hirsch. Zeitschrift, iii., 101) relates the following case: An inn-keeper, æt.
40 years, complained of constant pressure on the stomach, with frequent empty eructa-
tions, at times vomiting of small amounts of tenacious, rancid mucus, without a real
pyrosis, some constipation, and copious flow of saliva. He had to spit constantly. The
parotid gland was healthy, the tongue moist, without coating, and he had much thirst.
The smallest amount of food would satisfy his hunger, causing no gastric pain.
Urine scanty, rather brown. Countenance somewhat pale. Mental depression and
irritability. He attributes his condition to a cold taken some six months ago. There
is sensitiveness to pressure in the epigastric region toward the navel, and at a spot on
the spine corresponding to this. By putting the patient upon his back, with his legs
drawn close up, securing the greatest possible relaxation of the abdominal muscles, I
could discover a rather oblong, transversely-lying swelling. Considerable abdominal
pulsation; neither stomach, liver, nor spleen at all sensitive; a chronic inflammation
of the pancreas was clearly diagnosticated. The patient received the tincture of iodine
(6 drops of the tincture to 6 ounces of water, a tablespoonful at a dose). Decided
improvement in a week; the spitting of saliva ceased first; the vomiting disappeared,
then the empty eructations; appetite and digestion better; sensitiveness to pressure of
the parts involved very much better. The same prescription was continued, and the
patient discharged cured two weeks later.
Mercurius.-Reil says: Although the gastric pains which sooner or later
follow all mercurial preparations cannot well be traced directly to the pancreas, but
may arise from the stomach or liver, we may feel sure that the constant soft evacuations
from the bowels, the whitish, gray, greenish diarrhoea depends upon salivation of the
pancreas, in addition to the increase of the biliary secretion and of the intestinal mucus.
Mercury is certainly homoeopathic to acute pancreatitis; the soluble Mercury and
Calomel are to be preferred to the more powerful salts of Mercury." Buechner also
recommends Mercury, advising its use after the exhibition of Belladonna.
Belladonna.-Both Reil and Buechner class this polychrest among remedies
for pancreatic affections. The former recommends it in acute and chronic inflamma-
tion, hypertrophy, and even cancer; the latter says "catarrh of the pancreatic duct is
best met by Belladonna followed by Mercurius sol."-Baehr (Hirsch. N. Zeitschriften)
highly recommends the Atrop. sulph., and cites at least two cases in which the diag-
nosis was clearly established. Describing one case, that of a girl aged 24 years,
he says: The picture now became more clearly defined, and the diagnosis, pointing
directly to the pancreas, became positive. The appetite usually was poor, with occa-
sional spells of hunger Tongue slightly coated, taste bad. In the region immediately
below the stomach, a little toward the left, and also at a corresponding point in the
back, she experiences pain which is not so acute as it is unendurable and indescribable.
These are aggravated perhaps four or five hours after eating solid food, and are ac-
companied with vomiting of a reddish liquid resembling the juice of raw meat; the
latter contains much phlegm and food only if she has eaten solid food during the last
five hours preceding the vomiting; only once did the vomited matter contain blood.
Nausea rarely precedes the vomiting, which appears suddenly after a short exacerba-
tion of the pain; it is often exceedingly violent, and is usually followed by relief of the
pain. Rather deep pressure in the region above described is quite painful, but no en-
largement can be felt. Some headache; much exhaustion; the nights are restless,
and, on account of the vomiting she cannot sleep until morning. Great despondency;
very slight pyrexia. Occasional diarrhoea, alternating with constipation. Expression
of suffering, without much pallor. Of late, rapid emaciation. A cure was made by
Atrop. sulph., third dec. trituration.
Phosphorus “ may prove valuable in tuberculous patients, or when there are
evidences of fatty degeneration of various organs, especially of the heart, liver or kid-
neys; distressing burning pains in the coeliac axis; stools undigested, containing
particles of fat; face pale yellow; anæmia; atrophy of the pancreas with diabetes
mellitus. One of the best remedies in neuralgia of the cœliac plexus.
"The Phosphorus diarrhoea containing small particles like sago, or, as expressed by
some, like tallow, is not the fatty diarrhoea which suggests the drug in pancreatic dis-
eases." (E. A. Farrington.)
DISEASES OF THE ORGANS OF DIGESTION.
959
A study of the physiological action of Phosphorus strongly suggests the usefulness
of the remedy in various affections of the pancreas; yet there is no clinical testimony
to show that it has been satisfactorily used. Baehr points out that the "vomiting" of
Phosphorus may justify its exhibition in pancreatic affections, and Buechner (Hom.
Klin., 1873) merely mentions it in connection with fatty degeneration and in cancer
(medullary) of the pancreas. Soerge, who made and published an exhaustive study
of this remedy, recommends it in various affections of the stomach and intestine, but
has nothing to say in reference to its possible usefulness in pancreatic diseases.
Bearing in mind the great variety of symptoms which accompany
disease of the pancreas, and the manifold disorders in connection with
which evidently pancreatic disturbances are likely to arise, a very
large number of remedies may be suggested as possibly useful. Promi-
nent among these are Arsenicum, Lycopodium, Carbo, Conium, Aurum,
Calcarea, Uranium nitr.
肇
​INDEX TO VOL. I.
Abdomen, auscultation of, 91
mensuration of, 76
palpation of, 76
percussion of, 85
physical examination of, 73
regions of, 45
Abdominal dropsy, 849
Abscess, diffuse cervical, 556
in the walls of the stomach, 682
of the nasal cavity, 134
of pharynx, 551
retropharyngeal, 551
Acids, treatment of poisoning with, 630
Aconite, treatment of poisoning with, 631
Acute gastric catarrh, 616
Adhesions of heart and pericardium, 416
in connection with functional af-
Adiposis hepatica, 911
fections of the heart, 477
Ætiology, definition of, 20
Aortic valves, stenosis of the, 361
ætiology of, 292
Apneumatosis, 290
diagnosis of, 293
pathology of, 291
prognosis of, 293
symptoms of, 292
treatment of, 293
Arsenic, treatment of poisoning with, 631
Ascaris lumbricoides, 815
Ascites, 849
ætiology of, 849
diagnosis of, 852
differential diagnosis, 853
palpation in, SŎ
percussion in, 89
prognosis, 854
treatment, 854
Asthma, 306
Albuminoid disease of stomach, 683
Alcohol, treatment of poisoning with, 631
((
Alkalies,
Amyl nitrite,
Anal tumors, 801
((
((
Anesthesia of larynx, 154
631
((
631
Anchylostomum duodenale, 815, 820
Aneurism, abdominal, auscultation of, 93
palpation in, 85
active cardiac, 428
aortic, 483
cardiac, 385
Angina gangrenosa, 548
Ludovici, 555
pectoris, 464
ætiology of, 465
prognosis of, 469
symptoms of, 467
treatment of, 469
ætiology of, 309
bronchial, 192
cardiac, 194
catarrhal, 307
clinical history of, 308
diagnosis of, 311
hay, 307
humid, 308
latent, 307
Millar's, 308
peptic, 194
physical signs of, 311
prognosis of, 312
symptoms of, 309
treatment of, 313
varieties of, 307
tonsillaris, 525
Antimony salts of, treatment of poisoning
with, 631
Anus, fistula in the, 793
fissure in, 790
imperfections of, 779
tumors about the, 801
malformations of, 780
Aorta, abdominal, aneurism of, 485
aneurism of the, 482
atheroma of the, 481
diseases of the, 481
embolism of the, 491
stenosis of the, 490
prognosis, 487
treatment, 488
Aortic valves, lesions of the, 361
regurgitation of the, 362
Atelectasis pulmonum, 290
Atheroma of aorta, 481
great veins, 498
Atonic dyspepsia, 593
Atony of stomach, 593
Atrophy of stomach, 679
Atropia, treatment of poisoning with, 631
Auxiliary treatment, its province, 41
Bacilli tubercul., diagnostic value in phthisis
pulmonalis, 254
phthisis, Ehrlich's method of de-
(C
tecting them, 255
Gibb's method of detecting
them, 257
Smith's method of demon-
strating their presence
in the breath, 257
CC
631
Baryta, treatment of poisoning with, 631
Belladonna,
Bile-ducts, catarrh of the, 933
Bismuth, treatment of poisoning with, 631
VOL.I.-61
962
INDEX.
Bladder, palpation of the, 82
percussion of the, 90
Bowels, cancer of the, 777
obstruction of the, 745
ulceration of the, 770
Brain, symptoms in valvular affections of
the heart, 359
Bronchial asthma, 192
ætiology of, 192
Cancer of the pancreas, 953
peritoneum, article on, 845
pleura, article on, 329
rectum, article on, 799
stomach, 657
ætiology, 657
diagnosis, 661
Bronchitis, 173
climatic changes in, 202
diagnosis of, 199
pathology of, 197
physical signs of, 197
prognosis of, 199
symptoms of, 194
use of chloroform in, 202
use of nitre-paper in, 202
treatment, 200
varieties of, 193
auscultation in, 180
diagnosis of, 181
pathology of, 181
physical signs of, 179
percussion in, 180
position of organs in, 180
prognosis of, 182
treatment of, 183
varieties of, 182
Bronchitis, acute catarrhal, 173
ætiology, 173
morbid anatomy, 663
prognosis, 661
symptoms, 659
treatment, 664
tongue, article on, 521
Cantharides, treatment of poisoning with, 632
Capillary bronchitis, treatment of, 184
Cardiac dropsy, article on, 412
orifice, stricture of, 669
Cardialgia, article on, 606
Cardiasthenia, article on, 479
Carditis, article on, 422
Caseous phthisis, 236
Catarrh, acute nasal, 102
chronic nasal, 110
gastro-intestinal, 737
of bile-ducts, 933
ætiology, 933
diagnosis, 936
pathology, 934
prognosis, 936
symptoms, 935
cough of, 175
course of, 176
symptoms of, 174
Bronchitis, capillary, 177
capillary, duration and termination, 179
expectoration in, 178
febrile movements in, 178
gastric symptoms in, 178
Bronchitis, chronic, 185
chronic, bronchorrhoea, a form of, 186
catarrh, a form of, 186
diagnosis of, 188
fetid bronchitis, a form of, 187
pathology of, 189
treatment of, 189
winter cough, a form of, 186
Bronchitis, croupons, 190
croupous, ætiology of, 190
physical signs of, 191
treatment of, 192
Bronchophony, 59
Broncho-pneumonia, 215
Calculi, biliary, 873
Camphor, treatment of poisoning with, 631
Cancer of the bowels, article on, 777
liver, 916
ætiology, 916
diagnosis, 921
symptoms, 919
treatment, 921
varieties, 920
lungs, article on, 299
treatment, 937
of ileum and colon, 728
Catarrhal asthma, 307
phthisis, 236
sore throat, acute, 529
anatomical features, 530
symptoms, 531
treatment, 533
chronic, article on, 535
Cestoda, an order of intestinal parasites, 808
Cheeks, gangrene of the, 562
Chest, regions of the, 45
Chloral hydrate, treatment of poisoning
with, 632
Chlorine, treatment of poisoning with, 632
Chloroform, treatment of poisoning with, 632
Chlorosis, a cause of atonic dyspepsia, 595
Cholelithiasis, 873
Cholera biliosa, 734
infantum, 737
morbus, 734
nostras, 734
Chronic follicular sore throat, 537
ætiology, 537
anatomical features, 537
symptoms, 539
treatment, 541
gastric catarrh, 633
Cicatrization in penetrating ulcer of the
stomach, 651
Cirrhosis of the liver, 901
stomach, 675
Clergyman's sore throat, 537
Clinical thermometry, 30
Coagula (fibrinous) within the heart, 382
INDEX.
963
Coal gas, treatment of poisoning with, 632
Colic, article on, 717
Colitis, article on, 720
Concretions in the pancreas, 955
stomach, 680
Constipation, article on, 703
in functional affections of the
heart, 478
some remarkable cases of, 705
Contagion a cause of disease, 25
Contraction of the stomach, 679
Copper, salts of, treatment of poisoning with,
632
Coronary arteries, diseases of, 493
narrowing of, 427
Corrigan's pulse, 363
Coryza, 102
Cough in valvular affections of the heart, 381
Croton oil, treatment of poisoning with, 632
Croup, 159
ætiology of, 161
and diphtheria, differential diagno-
sis, 160
breathing in, 163
complications of, 167
course and termination, 168
diagnosis, 169
dyspnoea in, 164
exudation of 170
glandular enlargements in, 166
pain in, 167
pathology of, 168
prognosis, 170
remissions in, 166
treatment, 171
respiratory sounds, 164
varieties, 171
Cynanche cellularis maligna, 555
maligna, 548
tonsillaris, 525
Cysticerci, 808
Dental fistula, 508
Dentition, diseases of, 512
their therapeutics, 515
Diagnosis, a branch of medical science, 34
Diarrhoea, 728
ætiology, 728
diagnosis, 730
pathology, 729
prognosis, 731
Disease, age a predisposing canse, 21
climate, temperature, etc., as causes
of, 24
definition of, 17
exciting causes of, 27
habits of life as causes of, 22
individual peculiarities as causes
of, 21
inherited tendencies as causes of, 23
intermarriage as a cause of, 23
nomenclature of, 19
occupation as a cause of, 22
predisposing causes of, 20
previously existing, as a cause of, 24
sex as a predisposing cause of, 21
special causes of, 25
Diverticula a cause of obstruction of bowels,
755
Dropsy, cardiac, 412
from valvular disease of heart, its
treatment, 379
in valvular disease of the heart, 360
Duodenitis, article on, 701
Dysentery, article on, 721
Dyspepsia, atonic, 593
ætiology, 593
an exciting cause of other
diseases, 599
diagnosis and prognosis, 598
pathology, 595
symptoms of, 596
treatment of, 599
use of electricity in, 605
inflammatory, 616
Dysphagia spasmodica, 577
Dyspnea in valvular diseases of the heart,
treatment of, 381
Embolism of aorta, 491
great veins, 500
pulmonary artery, 493
Emphysema pulmonum, 285
Endemic diseases, their nature, 25
Endocardium, diseases of, 344
Endocarditis, 344
acute ulcerative, 348
diagnosis, 350
local applications
in, 352
pathology, 349
prognosis, 350
treatment, 731
varieties and symptoms, 729
Diarrhoea, bilious, description of, 729
colliquative, description of, 730
chronic, description of, 730
fæcal, description of, 729
lienteric, description of, 729
serous, description of, 729
Digitalis, treatment of poisoning with, 632
Dilatation of heart from valvular disease, 373
of stomach, article on, 672
Diphtheria and croup, differential diagno-
sis, 160
symptoms, 349
treatment, 350
simple, article on, 344
Enteralgia, article on, 683
Enteritis, article on, 690
folliculosa, 691
Entero-colitis, 691
symptoms of, 696
Epidemic diseases, their nature, 25
Epistaxis, 128
Epulis, 506
Ergot, treatment of poisoning with, 632
Ether,
632

964
INDEX.
Excesses, a cause of atonic dyspepsia, 595
Exciting cause of disease, 27
Fatty liver, article on, 911
Fibroid phthisis, 237, 250
Fistula, dental, 508
in ano, 793
treatment of, 795
salivary, 507
Flatulence in functional affections of the
heart, 479
Flux, 721
Foetal pulsation, 91
Follicular pharyngitis, 537
Food a factor in disease of the stomach, 680
Foreign bodies in the intestine causing
obstruction, 749
nasal cavity, 135
stomach, 680
Friction sounds in pleuritis, 58
Gall-bladder, palpation of, 77
Gall-stones, 873
ætiology, 877
chemical composition, 875
classification, 875
description, 873
diagnosis, 882
origin of, 876
prognosis, 883
symptoms, 878
treatment, 883
Gangrene of cheeks, 562
Gastralgia, 606
Gastric catarrh, acute, 616
diagnosis, 623
morbid anatomy of, 618
symptoms of, 621
as a concomitant, 623
chronic, 633
of drunkards, 622
of infauts, 622
Gastric fever, 616, 621
Gastritis, 616
chronic, 633
subacute, description of, 621
toxica, seu caustica, 628
treatment, 629
true, rarity of its occurrence, 621
Gastrodynia, 606
Gastromalacia, 677
Gibb's method of demonstrating the bacillus
tuberculosis, 257
Glass, treatment for swallowing of, 632
Glossitis, 519
Glossoplegia, 518
Gold, salts of, treatment in poisoning with,
632
Gum-boils, 505
Gums, diseases of, 505
fungoid tumors of, 507
Hæmatemesis, article on, 665
Hæmopericardium, article on, 415
Hæmoptysis, article on, 277
as a symptom of phthisis pulm., 233
Hæmorrhage from the intestines, article on,
709
from the lungs, article on, 278
nose, article on, 128
pancreas, article on, 952
stomach, article on, 665
in penetrating ulcer of the
stomach, 645
into the pericardial sac, 415
Hæmorrhoids, article on, 781
Hæmothorax, article on, 327
Hahnemann, on use of narcotics, etc., 41
on the treatment of intestinal
parasites, 817
Hay-asthma, 307
Hay-fever, article on, 124
Heart, adhesions of, 416
and pericardium, adhesions of, 416
adventitious products, 462
aneurism of, 385
atrophy of, 425
treatment, 426
varieties, 425
auscultation of the, 61
cancerous deposits in, 421
clots in, 382
dilatation of, 440
ætiology, 440
pathology and symp-
toms, 441
physical signs, 444
prognosis, 444
treatment, 445
diseases of nutrition, 340
dropsy of the, 412
fatty degeneration, 450
anatomy and pathology, 452
diagnosis, 457
prognosis, 458
symptoms of, 455
treatment of, 459
fatty overgrowth, 449
functional disorders, 474
functions of the, 336
hypertrophy of, 428
ætiology, 429
complications, 434
diagnosis, 432
pathological anatomy, 431
physical signs, 434
symptoms, 432
treatment, 435
varieties, 428
with dilatation, 438
inflammation of heart-muscle, 422
introduction to diseases of the, 330
irritability of, 474
murmurs of the, 63
nervous relationship of the, 341
neuroses of the, 464
palpation of the, 61
palpitation of the, article on, 474

INDEX.
965
Heart, percussion of the, 61
physical examination of the, 60
rupture of the, article on, 463
structure of the, 331
tuberculosis of, 420
valvular diseases, article on, 355
Iodine, treatment of poisoning by, 632
Iron (chloride, etc.), treatment of poisoning
by, 632
Irritable sphincter, 792
Jaundice, article on, 864
cough in, 381
dilatation from, 373
Kidney, palpation of the, 81
dropsy in, 379
hypertrophy in, 371
symptoms in valvular disease of the
heart, 359
Hepar adiposum, 911
Laryngeal phthisis, 142
ætiology, 143
diagnosis of, 146
Hepatic affections in functional disease of
heart, 479
colic from gall-stones, 881
cyst, 922
Hepatitis, acute, $85
diffuse, 894
Hepato-scirrhus, 916
Hernia, a cause of intestinal obstruction, 748
intestinalis, article on, 757
classification as to contents, 759
duration, 759
location, 758
reducibility, 759
irreducible, 765
reducible, 760
treatment of, 768
Humid asthma, 308
Hunter, Dr. John, on softening of the
stomach, 677
Hydatid tumors of the liver, article on, 922
Hydragogues, their use in cardiac dropsy,
380
Hydropericardium, 412
ætiology, 413
physical signs, 414
prognosis, 414
symptoms, 413
treatment, 415
Hydro-pneumothorax, 327
Hydrops abdominis, $49
Hydrothorax, 325
Hypertrophy, cardiac, from valvular disease
of the heart, treatment, 371
Hypertrophy of walls of stomach, 675
Icterus, article on, 864
Ileitis, article on, 728
Ileo-colitis, article on, 728
diagnosis, 677
Indigestion, general consideration of, 586
Infantile peritonitis, $34
Infection, a cause of disease, 25
Inflammatory dyspepsia (chronic), 633
Intestinal hemorrhage, article on, 709
obstruction, acute, article on, 745
chronic,
parasites, article on, 806
laryngeal appearance of, 144
pathology of, 143
symptoms of, 145
treatment of, 145
Laryngismus stridulus, article on, 152
Laryngitis, acute catarrhal, article on, 135
chronic, article on, 139
syphilitic, article on, 147
Laryngoscopy, 67
Larynx, anesthesia of the, 154
disease of its sensory system, 154
neuroses of, 147
paralysis of vocal cord, 148
physical examination of, 67
tumors and growths of, 155
Latent asthma, 307
Lead colic, 684
treatment of poisoning by, 632
Lime, treatment of poisoning by, 633
Liver, abscess of, 885
acute atrophy, 894
ætiology, $95
cerebral symptoms of, 899
diagnosis and prognosis,
900
duration of, 899
gastric symptoms, 898
pathology, 896
physical signs of, 897
symptoms of, 897
treatment of, 900
amyloid degeneration of, 929
cancer of, 916
chronic atrophy of, article on, 901
cirrhosis, 901
colloid, 929
congestion of, article on, 859
fatty, 911
granular, 901
hob-nailed, 901
hydatid tumor of, 922
interstitial inflammation of, 901
lardaceous, 929
753
palpation of the, 77
general therapeutics of, 825
varieties of, 807
Intestine, auscultation of, 91
palpation of, 79
percussion of, 89
Intussusception, a form of obstruction, 747
percussion of the, 85
scrofulous, 929
symptoms in valvular affections of
the heart, 358
waxy, 929
yellow atrophy of the, 894

966
INDEX.
Lung, auscultation of, 53
inspection of, 49
mensuration of, 49
normal sounds of, 51
palpation of 50
percussion of, 51
succussion of, 50
symptoms in valvular disease of the
heart, 358
syphilis of the, article on, 259
Lye, treatment of poisoning with, 633
Malaria a cause of cardialgia, 607
Meat, treatment of poisoning by spoiled, 633
Melæna, 709
Mercury, treatment of poisoning by, 633
Millar's asthma, 308
Mitral insufficiency, article on, 366
stenosis, 365
valve, lesions of, 365
Morphine, treatment of poisoning by, 633
Mushrooms,
(6
Myocarditis, article on, 422
Nares, physical examination of, 71
Nasal cavity, abscess, 134
foreign bodies in, 135
633
syphilitic affections of, 123
tumors of, 132
Neck, diffuse inflammation of connective
tissue, 555
Nematoda, order of intestinal parasites, 813
Nervous affections a cause of cardialgia, 607 1
Neuroses of the larynx, 147
Nux vom., treatment of poisoning by,
633
Obstruction of the bowels, article on, 745
Occlusion of the portal vein, 938
Odontalgia, article on, 508
Edema glottidis, article on, 138
(Esophagitis, article on, 564
Esophagocele, 570
Esophagus, dilatation of, 570
morbid growths in, 574
neuroses of, 577
organic stricture of, 567
paralysis of, 5×2
perforation and rupture of, 573
spasmodic stricture of, 577
Opium. treatment of poisoning by, 633
Ovarian tumors, percussion of, 91
Ovaries, palpation of, 84
Ozana, article on, 120
Oxyuris vermicularis, 814, 818
Pain, as a symptom in gastric affections, 586
of penetrating ulcer of
stomach, 643
Palpitation of the heart, 477
Pancreas, amyloid degeneration of, 952
cancer of, 953
concretions of, 955
description and functions of, 945
diseases of, 945
fatty degeneration of, 952
general therapeutics of, 956
Pancreas, hæmorrhage from, 952
tubercles of, 955
Pancreatitis, acute, 947
chronic, 950
Paralysis of abductor of one vocal cord, 149
abductor of both vocal cords, 150
adductor of one vocal cord, 148
adductor of both vocal cords, 149
intestines a factor in obstruction, 749
thyro-arytenoid muscle, 151
vocal cord, 148
Paris-green, treatment of poisoning with, 633
Pathological anatomy, definition and impor-
tance of, 27
Pathology, general, definition of, 18
special
Perforation of the stomach, 682
(C
18
from penetrating ulcer of the
stomach, 646
Pericarditis, 386
ætiology of, 387
anxiety and dyspnœa in, 397
area of dulness in, 402
cardiac impulse in, 402
cough, hiccough, vomiting in, 398
diagnosis of, 403
distension of intercostal spaces, 402
disturbance of rhythm, 397
dyspnoea in, 397
fever a symptom in, 396
fremitus in, 401
general character and varieties of,
386
increased epigastric fulness in,
402
increased mobility of apex-beat in,
402
insomnia in, 398
orthopnœa in, 398
pain as a symptom in, 395
palpitation
pathology of, 390
"397
pericardial friction murmurs in,
399
physical signs of, 399
prognosis of, 406
protrusion of chest-wall,
renal symptoms in, 398
symptoms of, 394
syncope in, 398
treatment of, 408
Pericardium, adhesions of, 416
diseases of, 386
Perichondritis laryngis, 142
Peritoneum, cancer of, 845
tubercles of, 840
Peritonitis, article on, 825
pelvic, 833
puerperal, 834
Pharyngitis catarrhalis, 529
Pharynx, abscess of, 551
diseases of, 529
Phlebitis, article on, 494
Phlebolites, 499
401

INDEX.
967
Phosphorus, treatment of poisoning with, 633
Phthisis, caseous, 236
catarrhalis, 236
fibroid, 237
florida, 250
laryngeal, 142, 258
pulmonalis, 220
ætiology of, 221
chest-pain in, 245
clubbed fingers and toes in,
249
contagiousness of, 221
cough in, 242
diagnosis of, 250
from bronchial dilatation,
253
from chronic bronchitis,
251
from chronic pleurisy,251
from pneumonia, 252
from chronic pulmonary
abscess, 253
from cancer, 252
from gangrene, 253
from syphilis, 252
diagnostic value of bacilli
tuberculosis, 254
diarrhoea in, 247
emaciation in, 247
expectoration in, 242
fever in, 245
hæmoptysis in, 243
menstrual suppression in,
248
mental symptoms in, 248
cedema of feet and ankles in,
249
pathology of, 233
physical signs of, 239
predisposing causes of, 230
predisposition as a cause of,
228
prognosis of, 259
pulse in, 246
respiration in, 247
symptoms of, 241
treatment of, 260
varieties of, 249
Physical diagnosis, 44
Picrotoxin, treatment of poisoning with, 633
Plastic linitis, 675
Plethora in functional affections of the heart,
477
Pleura, cancer of, 329
diseases of, 316
tubercle of, 328
Pleuritis, article on, 317
friction-sounds in, 58
Pleurodynia, 316
Pneumonia, article on, 202
acute lobar, 204
catarrhal, 215
eroupous, 204
lobular, 215
Pneumothorax, 326
Polypus narium, 132
Portal vein, occlusion of, 938
purulent inflammation of, 941
Procidentia recti, 788
Proctitis, article on, 803
Prognosis, a branch of medical science, 36
Prolapsus recti, 788
Prurigo ani, 801
Pulmonary apoplexy, 278
artery, diseases of, 491
embolism, 493
stenosis, 492
thrombosis, 493
cancer, article on, 299
treatment, 305
congestion, article on, 278
emphysema, 285
gangrene, 294
hæmorrhage, 278
œdema, 278
syphilis, 295
Pulmonic valves, disease of, 367
Pulse, its importance in diagnosis, 33
Pylephlebitis, 938
Pylethrombosis, 938
Pyloric orifice, stricture of, 671
Quinsy, 525
Râles, their importance as a sign, 56
Ranula, 524
Rectum, cancer of, 799
diseases of, 779
fissure of, 790
prolapse of, 788
stricture of, 796
tumors of, 793
ulcer of, 790
Regions of chest and abdomen, 45
Regurgitation, aortie, 362
Respiration in health and disease, 54
Retro-pharyngeal abscess, article on, 551
Rhinoscopy, 71
Rose-cold, 124
Round worm, 814
Rupture of the stomach, 682
Salivary fistula, 507
Sclerosis of stomach, 675
Seat-worm, 814
Secretion, perversion of gastric, a factor in
diseases of the stomach, 588
Silver salts of, treatment of poisoning by, 633
Sleeplessness in valvular disease of heart, 381
Smith's method of demonstrating the pres-
ence of bacillus tubercul., 257
Sore throat, acnte catarrhal, 529
cankered, 545
chronic catarrhal, 535
diphtheritic, 545
follicular, 537
gangrenous, 548
malignant, 548

968
INDEX
Sore throat, membranous, 545
putrid, 548
ulcerated, 542
Spleen, palpation of, 78
percussion of, 87
Sporadic cholera, 734
St. Martin, observations upon, 618
Stenosis of aorta, 490
aortic valve, 361
mitral valve, 365
pulmonary artery, 492
Stomach, abscess in walls of, 682
albuminoid disease of, 683
atrophy of, 679
auscultation of, 91
cancer of, 657
concretions in, 680
contraction of, 679
cramp of, 606
dilatation of, 672
fibroid induration of, 675
foreign bodies in, 680
hæmorrhage from, 665
hypertrophy of, 675
neuroses of, 606
palpation of, 78
penetrating ulcer of, 641
percussion of, 88
perforation of, 682
rupture of, 682
self-digestion of walls, 677
softening of, 677
stricture of cardiac orifice, 669
pyloric orifice, 671
tubercle of, 683
Stomatitis, 561
Stramonium, treatment of poisoning with,
633
Stricture, a factor in obstruction of bowels,
755
of rectum, 796
Strychnine, treatment of poisoning with, 633
Summer complaint, 737
Susceptibility to disease, 26
Swelled face, 511
Symptomatology, a branch of medical sci-
ence, 28
Symptoms, accidental, definition of, 29
diagnostic, 30
objective, 29
pathognomonic, 30
subjective, 28
Syphilis of larynx, 147
lung, 295
Syphilitic affections of nasal cavity, 123
Tænia solium, article on, 809
Tape-worm, 809
Therapeutics, general, 38
Thrombosis of the heart, 382
Thrush, 558
Tin, salts of, treatment of poisoning with, 633
Tongue, cancer of, 521
inflammation of, 519
paralysis of, 518
ulceration of, 523
Tonsillitis, 525
maligna, 548
Tonsils, hypertrophy of, 528
Toothache, 508
Treatment, auxiliary, of disease, 41
direct, of disease, 38
preventive, 37
Trichina spiralis, article on, 820
Trichocephalus dispar, 815
Tricuspid valve, diseases of, 368
Tuberculosis of pancreas, 955
peritoneum, 840
pleura, 328
stomach, 683
Tumors a factor in obstruction of the bowels,
756
about the anus, 801
of larynx, 155
of nasal cavity, 132
of rectum, 793
Typhlitis, article on, 712
Ulcer of stomach, penetrating, 641
Ulcerated sore throat, article on, 542
Ulceration of the bowels, article on, 770
Urine, physical examination of, 93
Uterine souffle, 92
Uterus, palpation of, 82
percussion of, 90
pregnant, auscultation of, 91
Valvular diseases of the heart, article on, 355
Varicosis, article on, 499
Vegetables, decayed, treatment of poison-
ing with, 633
Veins, atheroma of great veins, 498
diseases of great veins, 494
embolism of great veins, 500
thrombosis of great veins, 501
distant effects, 502
Veratrum, treatment of poisoning with, 633
Vocal resonance, abnormalities of, 59
Voice in health and disease, 58
Volvulus, a form of obstruction of bowels, 748
Vomiting a symptom in gastric affections, 589
diagnosis with reference to source
of, 590
in penetrating ulcer of stomach,
644
of blood, 665
treatment of, 591
Waxy liver, article on, 929
Worms in the intestines, 806
Zinc, treatment of poisoning with, 633
Zymotic diseases, definition of, 26
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