Home
  By Author [ A  B  C  D  E  F  G  H  I  J  K  L  M  N  O  P  Q  R  S  T  U  V  W  X  Y  Z |  Other Symbols ]
  By Title [ A  B  C  D  E  F  G  H  I  J  K  L  M  N  O  P  Q  R  S  T  U  V  W  X  Y  Z |  Other Symbols ]
  By Language
all Classics books content using ISYS

Download this book: [ ASCII | HTML | PDF ]

Look for this book on Amazon


We have new books nearly every day.
If you would like a news letter once a week or once a month
fill out this form and we will give you a summary of the books for that week or month by email.

´╗┐Title: A System of Practical Medicine by American Authors, Vol. I - Volume 1: Pathology and General Diseases
Author: Various
Language: English
As this book started as an ASCII text book there are no pictures available.
Copyright Status: Not copyrighted in the United States. If you live elsewhere check the laws of your country before downloading this ebook. See comments about copyright issues at end of book.

*** Start of this Doctrine Publishing Corporation Digital Book "A System of Practical Medicine by American Authors, Vol. I - Volume 1: Pathology and General Diseases" ***

This book is indexed by ISYS Web Indexing system to allow the reader find any word or number within the document.



Libraries)



A SYSTEM OF PRACTICAL MEDICINE.

BY AMERICAN AUTHORS.



EDITED BY

WILLIAM PEPPER, M.D., LL.D.,

PROVOST AND PROFESSOR OF THE THEORY AND PRACTICE OF MEDICINE AND OF
CLINICAL MEDICINE IN THE UNIVERSITY OF PENNSYLVANIA.


ASSISTED BY

LOUIS STARR, M.D.,

CLINICAL PROFESSOR OF DISEASES OF CHILDREN IN THE HOSPITAL OF THE
UNIVERSITY OF PENNSYLVANIA.



VOLUME I. PATHOLOGY AND GENERAL DISEASES.



PHILADELPHIA:

LEA BROTHERS & CO.

1885.



Entered according to Act of Congress, in the year 1885, by LEA
BROTHERS & CO., in the Office of the Librarian of Congress. All rights
reserved.



WESTCOTT & THOMSON, _Stereotypers and Electrotypers, Philada._

WILLIAM J. DORNAN, _Printer, Philada._



PREFACE.


The present work has been undertaken in the belief that by obtaining
the co-operation of a considerable number of physicians of
acknowledged authority, who should treat subjects selected by
themselves, there could be secured an amount of practical information
and teaching not otherwise accessible. It was determined to restrict
the selection of authors to those of this country--including
Canada--not from any want of recognition of the importance of the
studies of certain special subjects by European investigators, but
because it was felt that the proper time had arrived for the
presentation of the whole field of medicine as it is actually taught
and practised by its best representatives in America.

It is a matter of importance also that a comprehensive study shall be
made of the various forms of disease as occurring among our highly
composite population and under our varied and peculiar climatic
influences. Of course, in the present work comparative studies of this
kind must occupy a subordinate position; yet it cannot fail to enhance
both its interest and its value to have the various forms of disease
as they occur in this country discussed by those among us who are
confessedly the most competent and experienced.

The force of these observations must have been felt by the
distinguished men to whom I made application, for with scarcely an
exception they joined cordially in the laborious undertaking. I take
the greatest pleasure in testifying to the courtesy which has marked
all our relations, and which has lessened materially the labor and
strain inevitable in the production of such a work.

To ensure greater accuracy in the revision of the large amount of
proof-sheets, as well as to relieve me of some of the details
connected with the editorial work, I associated with myself Dr. THOMAS
HOLMES CATHCART, and, after sudden illness had cut short his very
promising career, I was fortunate in securing the assistance of Dr.
LOUIS STARR for the same purpose.

In order to render the work as valuable as possible to the general
practitioner, its scope has been made as comprehensive as could be
done without exceeding the limits prescribed by the nature of the
undertaking. This will be particularly noted in the section on
Gynaecology, where is presented a series of articles by eminent
specialists upon the subjects of chief importance to the general
practitioner, written with special reference to their constitutional
relations and their bearings on associated morbid conditions, while,
among the general diseases, a full article on puerperal fever has
properly been included. Important articles will also be found on
Tracheotomy, the Diseases of the Rectum and the Anus, and those of the
Bladder and the male sexual organs. Comprehensive sections have
further been provided, from the pens of distinguished specialists,
upon medical ophthalmology, medical otology, and on skin diseases,
presenting these large and complicated subjects in a clear and
practical light and with special reference to their relations to
general medical practice. In the presentation of such subjects as
hydrophobia, glanders, and anthrax care has been taken to ensure the
full discussion of these affections, not only as occurring in man, but
also in the lower animals, since it is highly important to provide the
physician with authoritative information on at least such points of
Veterinary Science as have a direct practical bearing on morbid
processes in man.

In view of the intimate relations of all questions of hygiene to the
causation and prevention of disease, in regard to which medical men
are constantly consulted, and are, indeed, often obliged to assume
weighty responsibilities, interesting articles on Drainage and Hygiene
have been provided.

In order to avoid repetition and confusion, and at the same time to
secure a comprehensive presentation of the subjects of General
Pathology and of General Etiology, Symptomatology, and Diagnosis,
considerable space has been devoted to their full discussion. The
chapter on General Morbid Processes will be found to convey distinct
and conservative teaching on all points included under that
comprehensive title, and will thus supply a solid basis for the
subsequent discussions of special morbid conditions. In any work on
General Medicine at the present day frequent allusion must be made to
the relations of various low organisms to morbid processes. This
question--or rather the series of questions which arise in connection
with this subject, and which at present form the most fruitful topic
of discussion and of investigation--will be found treated by different
authors in various places and from various standpoints. No attempt has
been made to secure uniformity of views upon a matter which is still
_sub judice_, and which demands much more skilful and critical
investigation before its true scientific position has been finally
determined. It has even been felt to be desirable to allow a certain
amount of repetition, which has naturally resulted from the
introduction of this discussion, not only in the chapter on General
Etiology, but in connection with the causation of scarlatina,
diphtheria, hydrophobia, pyaemia, puerperal fever, and phthisis.

Throughout the work the chief purpose of the editor and of his
collaborators, to furnish a concise and thoroughly practical system of
medicine, has compelled the omission of bibliographical lists, of
numerous references, and of extended discussions of theoretical views
or of controverted questions, in order that more space might be
devoted to clear descriptions of disease and to a full presentation of
the subjects of diagnosis and treatment. If it should seem, in
consequence, that inadequate recognition has been made of the labors
of others, it must be borne in mind that ample quotations and numerous
references were inadmissible in such a work as the present.

       *       *       *       *       *

The classification and nomenclature which have been adopted are those
recommended by the Royal College of Physicians of England and by the
American Medical Association. Charts and tables have been inserted
wherever they were needed to elucidate the text, but after mature
reflection it was felt necessary to omit all illustrations that were
not imperatively required, although many original drawings and
paintings of high value were offered with the articles.

THE EDITOR.

OCTOBER, 1884.



CONTENTS OF VOL. I.


                                                                  PAGE
PREFACE . . . . . . . . . . . . . . . . . . . . . . . . . . . . .    3


    GENERAL PATHOLOGY AND SANITARY SCIENCE.

GENERAL MORBID PROCESSES. By REGINALD H. FITZ, M.D. . . . . . . .   35

GENERAL ETIOLOGY, MEDICAL DIAGNOSIS, AND PROGNOSIS. By HENRY
  HARTSHORNE, M.D., LL.D. . . . . . . . . . . . . . . . . . . . .  125

HYGIENE. By JOHN S. BILLINGS, A.M., M.D., LL.D. (Edin.) . . . . .  173

DRAINAGE AND SEWERAGE IN THEIR HYGIENIC RELATIONS. By GEORGE E.
  WARING, JR., M. Inst. C.E.  . . . . . . . . . . . . . . . . . .  213


    GENERAL DISEASES.

SIMPLE CONTINUED FEVER. By JAMES H. HUTCHINSON, M.D.  . . . . . .  231

TYPHOID FEVER. By JAMES H. HUTCHINSON, M.D. . . . . . . . . . . .  237

TYPHUS FEVER. By JAMES H. HUTCHINSON, M.D.  . . . . . . . . . . .  338

RELAPSING FEVER. By WILLIAM PEPPER, M.D., LL.D. . . . . . . . . .  369

VARIOLA. By JAMES NEVINS HYDE, M.D. . . . . . . . . . . . . . . .  434

VACCINIA. By FRANK P. FOSTER, M.D.  . . . . . . . . . . . . . . .  455

VARICELLA. By JAMES NEVINS HYDE, M.D. . . . . . . . . . . . . . .  481

SCARLET FEVER. By J. LEWIS SMITH, M.D.  . . . . . . . . . . . . .  486

RUBEOLA. By W. A. HARDAWAY, A.M., M.D.  . . . . . . . . . . . . .  557

ROTHELN. By W. A. HARDAWAY, A.M., M.D.  . . . . . . . . . . . . .  582

MALARIAL FEVERS. By SAMUEL M. BEMISS, M.D.  . . . . . . . . . . .  589

PAROTITIS. By JOHN M. KEATING, M.D. . . . . . . . . . . . . . . .  620

ERYSIPELAS. By JAMES NEVINS HYDE, M.D.  . . . . . . . . . . . . .  629

YELLOW FEVER. By SAMUEL M. BEMISS, M.D. . . . . . . . . . . . . .  640

DIPHTHERIA. By ABRAHAM JACOBI, M.D. . . . . . . . . . . . . . . .  656

CHOLERA. By ALFRED STILLE, M.D., LL.D.  . . . . . . . . . . . . .  715

PLAGUE. By JAMES C. WILSON, A.M., M.D.  . . . . . . . . . . . . .  771

LEPROSY. By JAMES C. WHITE, M.D.  . . . . . . . . . . . . . . . .  785

EPIDEMIC CEREBRO-SPINAL MENINGITIS. By A. STILLE, M.D., LL.D. . .  795

PERTUSSIS. By JOHN M. KEATING, M.D. . . . . . . . . . . . . . . .  836

INFLUENZA. By JAMES C. WILSON, A.M., M.D. . . . . . . . . . . . .  851

DENGUE. By H. D. SCHMIDT, M.D.  . . . . . . . . . . . . . . . . .  879

RABIES AND HYDROPHOBIA. By JAMES LAW, F.R.C.V.S.  . . . . . . . .  886

GLANDERS AND FARCY. By JAMES LAW, F.R.C.V.S.  . . . . . . . . . .  909

ANTHRAX (MALIGNANT PUSTULE). By JAMES LAW, F.R.C.V.S. . . . . . .  926

PYAEMIA AND SEPTICAEMIA. By B. A. WATSON, A.M., M.D.  . . . . . .  945

PUERPERAL FEVER. By WILLIAM T. LUSK, M.D. . . . . . . . . . . . .  984

BERIBERI. By DUANE B. SIMMONS, M.D. . . . . . . . . . . . . . . . 1038


INDEX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1045



CONTRIBUTORS TO VOL. I.


BEMISS, SAMUEL M., M.D.,
    Professor of Theory and Practice of Medicine and Clinical Medicine
      in the University of Louisiana, New Orleans.

BILLINGS, JOHN S., A.M., M.D., LL.D. (Edin.),
    Surgeon U.S. Army, Washington.

FITZ, REGINALD H., M.D.,
    Shattuck Professor of Pathological Anatomy in Harvard University,
      Boston.

FOSTER, FRANK P., M.D.,
    New York.

HARDAWAY, W. A., A.M., M.D.,
    Professor of Diseases of the Skin in the St. Louis Post-Graduate
      School of Medicine and in the Missouri Medical College, St.
      Louis; President of the American Dermatological Association.

HARTSHORNE, HENRY, M.D., LL.D.,
    Late Professor of Hygiene in the University of Pennsylvania,
      Philadelphia.

HUTCHINSON, JAMES H., M.D.,
    Physician to the Pennsylvania Hospital and to the Children's
      Hospital, Philadelphia.

HYDE, JAMES NEVINS, M.D.,
    Professor of Skin and Venereal Diseases in the Rush Medical
      College, Chicago.

JACOBI, ABRAHAM, M.D.,
    Clinical Professor of Diseases of Children in the College of
      Physicians and Surgeons, New York, etc.

KEATING, JOHN M., M.D.,
    Visiting Obstetrician and Lecturer on Diseases of Women and
      Children to the Philadelphia (Blockley) Hospital; Surgeon to the
      Maternity Hospital; Physician to St. Joseph's Hospital,
      Philadelphia.

LAW, JAMES, F.R.C.V.S.,
    Professor of Veterinary Science in Cornell University, Ithaca,
      N.Y.

LUSK, WILLIAM T., M.D.,
    Professor of Obstetrics and Diseases of Women and Children in the
      Bellevue Hospital Medical College, New York.

PEPPER, WILLIAM, M.D., LL.D.,
    Provost and Professor of the Theory and Practice of Medicine and
      of Clinical Medicine in the University of Pennsylvania,
      Philadelphia.

SCHMIDT, H. D., M.D.,
    Pathologist to the Charity Hospital, New Orleans.

SIMMONS, DUANE B., M.D., Yokohama, Japan,
    Late Director, Physician, and Surgeon-in-Chief of the Government
    Hospital, also Consulting Surgeon to Prison and Police Hospitals
    at Yokohama, Japan.

SMITH, J. LEWIS, M.D.,
    Clinical Professor of Diseases of Children in the Bellevue
      Hospital Medical College, New York.

STILLE, ALFRED, M.D., LL.D.,
    Emeritus Professor of Theory and Practice of Medicine in the
      University of Pennsylvania, Philadelphia.

WARING, GEORGE E., JR., M. Inst. C.E.,
    Engineer of Sanitary Drainage, Newport, R.I.

WATSON, B. A., A.M., M.D.,
    Surgeon to the Jersey City Charity, St. Francis, and Christ
      Hospitals, Jersey City, N.J.

WHITE, JAMES C., M.D.,
    Professor of Dermatology in Harvard University, Boston.

WILSON, JAMES C., A.M., M.D.,
    Physician to the Jefferson Medical College Hospital and to the
      Philadelphia Hospital, Philadelphia.



ILLUSTRATIONS.


FIGURE                                                            PAGE
 1. MICROCOCCI  . . . . . . . . . . . . . . . . . . . . . . . . .  142

 2. BACTERIA  . . . . . . . . . . . . . . . . . . . . . . . . . .  142

 3. BACILLUS MALARIAE . . . . . . . . . . . . . . . . . . . . . .  143

 4. BACTERIA FROM GELATIN SOLUTION  . . . . . . . . . . . . . . .  143

 5. VIBRIOS IN GELATIN CULTURE-FLUID  . . . . . . . . . . . . . .  144

 6. PROTOCOCCUS FROM SLIDES EXPOSED OVER SWAMP-MUD  . . . . . . .  144

 7. BACILLI FROM SWAMP-MUD  . . . . . . . . . . . . . . . . . . .  145

 8. BACILLI FROM SEPTICAEMIC RABBIT . . . . . . . . . . . . . . .  145

 9. BACILLI FROM HUMAN SALIVA . . . . . . . . . . . . . . . . . .  146

10. BACILLUS ANTHRACIS  . . . . . . . . . . . . . . . . . . . . .  146

11. BACILLUS TUBERCULOSIS . . . . . . . . . . . . . . . . . . . .  147

12. CHART OF TYPICAL RANGE OF TEMPERATURE IN TYPHOID FEVER, AFTER
      WUNDERLICH  . . . . . . . . . . . . . . . . . . . . . . . .  282

13. CHART SHOWING RECRUDESCENCE OF FEVER FROM INDISCRETION OF
      DIET. . . . . . . . . . . . . . . . . . . . . . . . . . . .  283

14. CHART SHOWING FALL OF TEMPERATURE FROM INTESTINAL HEMORRHAGE
      IN TYPHOID FEVER  . . . . . . . . . . . . . . . . . . . . .  284

15. PULSE-TRACING IN RELAPSES OF TYPHOID FEVER  . . . . . . . . .  304

16. CHART OF TEMPERATURE IN TYPHOID FEVER WITH RELAPSE.--ORIGINAL
      ATTACK  . . . . . . . . . . . . . . . . . . . . . . . . . .  306

17. CHART OF TEMPERATURE IN TYPHOID FEVER WITH RELAPSE.--RELAPSE   306

18. TEMPERATURE CHART OF TYPHOID FEVER.--ABORTIVE ATTACK,
      FOLLOWED BY TYPICAL ATTACK  . . . . . . . . . . . . . . . .  308

19. SPIRILLUM FROM THE BLOOD IN A CASE OF RELAPSING FEVER . . . .  374

20. TEMPERATURE CHART OF TYPICAL CASE OF RELAPSING FEVER, WITH
      THREE RELAPSES TERMINATING IN RECOVERY  . . . . . . . . . .  379

21. TEMPERATURE CHART OF TYPICAL CASE OF RELAPSING FEVER,
      TERMINATING IN RECOVERY . . . . . . . . . . . . . . . . . .  380

22. TEMPERATURE CHART FROM A CASE OF THE BILIOUS TYPHOID OR GRAVE
      SUBINTRANT FORM OF RELAPSING FEVER  . . . . . . . . . . . .  397

23. TEMPERATURE CHART SHOWING THE LAPSE OF A REMITTENT FEVER INTO
      AN INTERMITTENT . . . . . . . . . . . . . . . . . . . . . .  600

24. CHARTS SHOWING THE TEMPERATURE CURVE IN TYPHO-MALARIAL FEVER:
      PART I., SHOWING PREDOMINANCE OF TYPHOIDAL ELEMENT;
      PART II., SHOWING PREDOMINANCE OF MALARIAL ELEMENT  . . . .  617



GENERAL PATHOLOGY.


GENERAL MORBID PROCESSES.

GENERAL ETIOLOGY.

HYGIENE AND QUARANTINE.

DRAINAGE AND SEWERAGE IN RELATION TO THE PREVENTION OF DISEASE.



{35}

GENERAL MORBID PROCESSES.[1]

INFLAMMATION; THROMBOSIS AND EMBOLISM; EFFUSIONS; DEGENERATIONS;
TUBERCULOSIS; MORBID GROWTHS.

BY REGINALD H. FITZ, M.D.

[Footnote 1: In the preparation of this subject full and free use has
been made of the following works: _Die Cellular Pathologie_, Virchow,
4te Auflage, Berlin, 1871; _Handbuch der Allgemeinen Pathologie_, Uhle
und Wagner, 7te Auflage, Leipzig, 1876; _Handbuch der Allgemeinen
Pathologie als Pathologische Physiologie_, Samuel, Stuttgart, 1879;
_Vorlesungen uber Allgemeine Pathologie_, Cohnheim, 2te Auflage,
Berlin, 1882; _Lehrbuch der Pathologischen Anatomie_,
Birch-Hirschfeld, 2te Auflage, 1er Band, Leipzig, 1882; _Lehrbuch der
Allgemeinen und Speciellen Pathologischen Anatomie_, Ziegler, 1er und
2er Theil, Jena, 1882 and 1883.]


GENERAL MORBID PROCESSES.


Disease is to be regarded as representing the result of a series of
processes called morbid or pathological, from the fact that they are
manifested by disturbances in the organism.

The processes concerned are the same in kind as those essential to
health, but they are modified in time, place, or quantity.

Morbid processes, therefore, are to be considered as modified
physiological processes tending to cause disease.

All physiological processes are subject to certain variations which
tend to produce disturbances in the functions of the body. In the
healthy organism this tendency is checked by the automatic regulators
of the functional activity of the various organs, to the importance of
which Virchow[2] long ago called attention. By their action the
influence of external agents is controlled within certain limits. The
lids close and prevent injury to the eye. Sneezing, coughing, and
vomiting bring about the expulsion of noxious irritants. Sweating aids
in neutralizing the injurious effects of exposure to high
temperatures. Rapid respiration permits a sufficient cleansing of the
blood in rarefied atmospheres. When the limits, within which the
regulation of physiological processes is possible, are exceeded, such
processes become pathological and disease begins. A morbid process,
therefore, is usually incapable of recognition till disease is
present. It may exist and disease be unsuspected and denied. A
diminished blood-supply may be one link in the process which
eventually leads to the production of disturbances. {36} Another link
is to be found in the fatty degeneration resulting from this lack of
blood.

[Footnote 2: _Handbuch der Speciellen Pathologie und Therapie_,
Virchow, 1er Band, p. 15, Erlangen, 1854.]

Such a degeneration may have long existed in the walls of a
blood-vessel, and yet the individual appear in the best of health. The
sudden rupture of the weakened wall results in death or disease. With
the manifestation of the disturbances which render the condition of
the vessel obvious the individual is said to be diseased.

In most instances, however, the morbid process makes itself early
apparent. Disturbances of nutrition, formation, or function soon
become sufficient in quantity to attract attention from the resulting
discomfort, and the presence of disease is then recognized. The latter
is thus essentially a conventional term, and begins when the morbid
processes occasion a sufficient degree of inconvenience.

The process is never at a standstill. It either tends toward a return
to the physiological conditions, or its course is in the direction of
their destruction. As physiological processes are absolutely dependent
upon the vitality of the elements of the tissues, so those which have
become pathological cease to exist with the death of such elements. In
the dead body there is no disease, although its results remain, and
furnish the most efficient means of identifying the processes which
occasioned them.

In the study of morbid processes, therefore, one must appreciate the
normal conditions and manifestations of life in the individual.
Physiological laws govern pathological phenomena, and the latter must
always be submitted to the tests furnished by the former.

Just as little, however, as the study of anatomy familiarizes the
student with the anatomical changes resulting from diseased processes,
does the study of physiology accustom the student to the features of
disease. Pathological processes must be studied by themselves and for
themselves, although the means which are employed may be the same as
those used in physiological research.

It is evident that the exactness of method which is the demand of the
physiological investigator cannot be secured by the pathologist. The
material of the latter lies farther, beyond his control. Nevertheless,
much of the ground to be gone over is common, and the object sought
for is essentially the same--the knowledge of the conditions necessary
to maintain life.

In an introduction to the study of disease there are certain processes
which deserve early recognition. They are both the cause and the
result of disease, and may occur in various diseases, either limited
to one organ or present in a series of organs. Their treatment at
present obviates the necessity of repetition, and prepares the reader
for the special consideration of their occurrence in the various
structures and systems of the body.

These processes are named in virtue of some prominent characteristic,
and each is made up of a complex series of conditions and
disturbances. In part, they represent modifications in the circulation
of blood and lymph; in part, they consist of nutritive derangements,
whose consequences appear as the various degenerations, or as the
additions to the body, the new formations.

The processes and groups of processes in question are those included
under the following heads: inflammation; thrombosis and embolism;
effusions; degenerations; tuberculosis; and morbid growths.


{37} Inflammation.

Inflammation is characterized now, as in the time of Galen, by the
presence of redness, heat, swelling, and pain. The disturbance of
function, added to modern definitions, is to be regarded either as a
result or a cause, or both, of the variously modified physiological
processes whose sum is the inflammation.

The redness of inflammation is obviously dependent upon the presence
of an increased quantity of blood. This is readily apparent in the
direct observation of the blood-vessels of an inflamed, transparent
part of the body, as the mesentery of the frog or rabbit, or the
tongue and webbed foot of the former animal. The redness of
inflammation consequently demands the presence of blood-vessels in the
affected region, and becomes all the greater the more vascular the
part--_i.e._ the richer it is in such vessels.

Redness does not suffice for the existence of inflammation, for it may
be found in the absence of other evidence of the latter. The diffused
redness, often extensive, of birth-marks, that from venous obstruction
or temporary congestions, from vaso-motor disturbances--the section of
the sympathetic furnishing a well-known instance--are examples of
non-inflammatory redness. Inflammation may even be present without
redness, as may be constantly observed in the occurrence of
parenchymatous inflammation and of the chronic interstitial varieties.

The heat of inflammation is one of the most important clinical
features, yet not indispensable, as appears from its absence in
chronic interstitial forms of inflammation. In the acute varieties of
inflammation an elevated temperature is constant, and its observation
and record furnish a most valuable means of determining the beginning
and progress of an inflammation, which, for a time, may furnish but
little additional evidence.

The heat of inflammation is the prominent characteristic of
inflammatory fever, and it is the study of this variety of fever of
late years which has resulted in an intelligible and relatively
satisfactory theory concerning fevers in general. Information of much
value is to be found in the recent work of Wood,[3] which contains
abundant historical information, as well as extensive original
observations and conclusions.

[Footnote 3: _Fever: A Study in Morbid and Normal Physiology_, H. C.
Wood, A.M., M.D., Philadelphia, 1880. (Reprint from the _Smithsonian
Contributions to Knowledge_, No. 357.)]

Inflammatory fevers are distinguished from idiopathic forms. The
latter variety includes the occurrence of fever as an attribute of the
disease concerned, the more characteristic symptoms of which follow
the febrile outbreak. Local inflammatory processes may take place
during the progress of the disease with its fever, but such processes
are co-effects of the cause of the latter, rather than its cause. Most
of those diseases in which fever occurs as one of the joint effects of
the cause of the disease, are included among the infective or zymotic
classes.

The inflammatory fevers are those attending an acute inflammatory
process, and are secondary to, and occasioned by, the latter. The type
of this variety is seen in the fever occurring during the progress of
a wound, whether its course is toward healing or extension. Such {38}
traumatic fevers are characterized as septic or aseptic; the former
including the conditions of septicaemia and pyaemia. The aseptic
traumatic fevers, as described by Volkmann,[4] are those which pursue
their course with an elevated temperature, but without most of the
other febrile phenomena.

[Footnote 4: _Beitrage zur Chirurgie_, Leipzig, 1875, p. 24; _Sammlung
Klinischer Vortrage_, No. 121, Genzmer und Volkmann.]

Fever in general is characterized by a combination of disturbances in
the physiological processes of the body. Such processes are those
concerned in the production and dissipation of heat, in respiration
and circulation, digestion and secretion, and in mental, motor, and
other sensorial action. Such disturbances are manifested by a
persistent elevation of temperature, an increased destruction of
tissue, a quickened and modified pulse, accelerated breathing,
increased thirst, diminished appetite, and diminished quantity and
altered quality of the secretions. The sensorial disturbances include
wakefulness and stupor, headache, delirium, twitchings, cramps, and
other symptoms indicative of functional impairment of the nervous
system.

Of all these manifold evidences of fever, the elevation of temperature
is the one whose cause, range, and results have been most carefully
and critically investigated. No record of a case in which fever is
present is regarded as complete without the chart of the daily
variations in temperature, respiration, and circulation. The practical
value of such records is thus admitted, and in the experiments
relating to the origin of animal heat the observations of temperature
are as essential as the chemical analyses, each of which supplements
the other.

The more accurate determination of the heat produced in the body is
obtained either by the use of the calorimeter (an apparatus for
measuring the collected heat liberated from the body) or by estimating
the quantity of heat produced in the destruction of the constituents
of the body from quantitative analyses of the discharged carbonic acid
and urea. The results of such investigations are regarded by
Rosenthal[5] as possessing only a relative value, but justify the
conclusion that most of the heat produced in the organism results from
the oxidation of its constituents.

[Footnote 5: _Hermann's Handbuch der Physiologie_, Leipzig, 1882, iv.
2, 375.]

For the preservation of health it is essential that this heat should
be removed from the body in such quantity that the temperature of the
latter shall not vary to any considerable extent, for any considerable
time, from 37.2 degrees C. (98.4 degrees F.). The removal of the heat
is mainly accomplished by its radiation or conduction into a
surrounding cooler medium, and by the evaporation of moisture from the
surface of the body. Too great a removal of heat results in death from
freezing, while too great an accumulation of heat terminates fatally
from the effects of an unduly elevated temperature. To ensure the
normal range of temperature, constantly changing relations must exist
between the production of heat and its dissipation. The cooler the
surroundings, the more must heat be produced, or the less must heat be
evolved from the body.

An increased production of heat is obvious under conditions of climate
demanding prolonged exposure to low temperature. An abundantly fatty
diet promotes the formation of heat, while suitable clothing checks
its dissipation. Although it is claimed by Liebermeister that sudden
exposure to cold stimulates heat-production, Rosenthal[6] disputes
this {39} statement, and maintains that it is still to be regarded as
doubtful whether the production of heat can be varied to suit the
demands of sudden and temporary changes of temperature. With the
admission of this doubt, the regulation of the temperature of the
body, under the circumstances just referred to, is mainly accomplished
through the influence of agencies favoring or checking the loss of
heat. Since heat is largely brought to the surfaces of the body by the
circulating blood, modifications in the fulness and rapidity of this
superficial current produce corresponding differences in the amount of
heat and moisture presented. Such variations are considered to be
accomplished through the action of the vaso-motor nervous system,
whose differing effects are apparent in the pale, cool skin and the
flushed, warm surface.

[Footnote 6: _Op. cit._, 413.]

The search for the regulation of such vaso-motor action has led to the
view that the production of heat, as well as its dissipation, may be
influenced from a nervous centre. Wood[7] claims that the result of
experiments made by him proves the existence of such a heat-centre in
or above the pons. Although admitting the possibility of its being a
muscular vaso-motor centre, he regards it rather as an inhibitory
heat-centre, which acts, as suggested by Tscheschichin, by repressing
the chemical changes in the constituents of the body through which
heat is produced.

[Footnote 7: _Op. cit._, 254.]

This view is objected to by Rosenthal,[8] on the ground that the facts
are not universally agreed upon, and their interpretation is somewhat
vague. Even the increased production of heat as determined by Wood, if
admitted, may be regarded as the result of a modified circulation.

[Footnote 8: _Op. cit._, 442.]

The preservation of a normal range of temperature in general is to be
recognized as the result of variations in the relation of
heat-production to heat-dissipation. The causes which influence this
relation may act from without or from within, and are regarded as
producing their effect by means of the vaso-motor nervous system. The
causes which act from within are those concerned in the febrile
elevation of temperature. Whether the latter is associated with, or
independent of, inflammatory processes, the question of first
importance relates to the modification of physiological conditions.
The causes of the physiological production of heat and its dissipation
have already been referred to, and the same elements demand
consideration in the pathological range of temperature so striking in
fever.

Relatively accurate inductions with regard to the origin of febrile
heat were first rendered possible by the experiments of Billroth and
Weber. These observers found that the introduction of putrid material
into the circulation of animals produced fever. It was afterward shown
that various substances, not necessarily of a putrid character, might
produce the same result.

From measurements with the calorimeter of the heat produced, it was
concluded by Wood[9] that in the fever of pyaemic dogs more heat was
produced than in healthy, fasting dogs, although less than in
high-fed, healthy dogs. An increased production of heat in the fevered
animal is thus obvious, as his capacity to receive and assimilate food
is considerably less than that of a high-fed, healthy dog. The
calculations of Sanderson, referred to by Wood,[10] based upon the
analyses of eliminated carbonic {40} acid and urea, show that the
febrile human subject produces very much more heat than the fasting,
though less than the fully-fed, healthy, man.

[Footnote 9: _Op. cit._, 236.]

[Footnote 10: _Op. cit._, 239.]

An increased production of heat in fever is generally admitted,
although it alone is not to be regarded as the essential feature in
the elevated range of the temperature. The fasting man or animal under
ordinary circumstances is not febrile, and an increased production of
heat from full feeding in health, equal to that observed in fever, not
being associated with fever, it is apparent that the retention of the
produced heat is of importance for the existence of fever. Although it
has been shown by various observers that more heat is dissipated
during fever than in health, this increased loss is not in proportion
to the increased production of heat. A persistent elevation of
temperature is the necessary result. This elevation is subject to
daily and hourly differences, as is the temperature of the healthy
individual. These variations in the range of the febrile temperature
are apparently due to an agency like that which dominates the course
of normal temperatures--viz. a varying action of the vaso-motor
nervous apparatus, as well as of that controlling the secretion of
sweat, now permitting, now checking, the dissipation of the produced
heat.

For the existence of the elevated temperature of fever, therefore,
there is demanded the presence of an agent within the body which, as
stated by Wood,[11] shall act "upon the nervous system which regulates
the production and dissipation of animal heat--a system composed of
diverse parts so accustomed to act continually in unison in health
that they become, as it were, one system and suffer in disease
together." It may be that there exists, as claimed by Wood and
Tscheschichin, a heat-centre independent of the vaso-motor and other
centres, through which heat is dissipated, or it may be, as maintained
by Rosenthal, that the vaso-motor system alone is concerned in the
regulation of temperature. Such action may be inhibitory or excitant,
according to the views of the one or the other author, without
affecting the main question as above stated.

[Footnote 11: _Op. cit._, 255.]

The elevation of temperature suffices to explain for the most part
certain of the other phenomena of fever, as thirst, digestive
disturbances, increased respiration, and emaciation. A coincident
affection of various cerebro-spinal centres is demanded to explain the
altered action of the heart and the numerous nervous symptoms which
are to be found in fever. The agent producing such manifold effects is
obviously no unit. It may be introduced from without or it may arise
within the body, and its transfer to the nervous centres is
undoubtedly accomplished through the circulation.

Among those agents which act from without are to be included the
specific causes of infective diseases. It is probable that these
produce the fever, as they occasion other symptoms of the disease, and
their action may be regarded as direct, or indirect through the
secondary products of their own vital changes. In the light of the
existing facts the products of minute organisms developed outside the
human body may give rise to fever when introduced, without the
organism, into the body. The history of septicaemia contains numerous
illustrations of the pyrogenetic properties of material produced in
connection with wounded surfaces of the body exposed to the action of
minute organisms. The introduction of blood of the same, or of a
different animal, into the {41} circulation of a given animal is
followed by fever, as is the injection of considerable quantities of
water into the blood-vessels. The same is true of various chemical
substances.

It is further obvious that the agents producing fever may arise within
the body. The fever resulting from the deprivation of water, and from
the destruction of tissues, are instances of the probable origin of
pyrogenetic substances from the rapid metamorphosis of tissues.

It is suggested by Samuel[12] that under given circumstances the fever
may be sanatory. This view is based upon the probability that certain
parasitic organisms are destroyed at such temperatures as may be
produced within the body. The growth of the bacillus of malignant
pustule takes place most vigorously at a temperature of 30.5 degrees
C. (95 degrees F.), while its development is feeble at 40 degrees C.
(104 degrees F.). The bacillus of tuberculosis, as shown by Koch,
thrives at temperatures between 37 degrees C. (98.6 degrees F.) and 38
degrees C. (100.4 degrees F.), but its growth ceases at temperatures
above 41 degrees C. (105.8 degrees F.). The spiral fibre of relapsing
fever, which is present in the blood in great abundance at the
beginning of the febrile onset, disappears at the close, the
temperature being 42 degrees C. (107.6 degrees F.). It is not to be
found in the intervals between the febrile paroxysms, but reappears a
few hours before the recurrence of the fever. The history of
intermittent fever suggests a similar relation between its cause and
the febrile periods.

[Footnote 12: _Op. cit._, 155.]

The value of pain as evidence of inflammation is merely relative. Its
existence depends upon the presence of sensitive nerves, and those
inflammations are the least painful which occur in parts where such
nerves are fewest.

The pain of inflammation is attributable to the pressure upon the
nerves of that product of the inflammation known as the exudation.
This pressure becomes all the greater the more abundant the exudation,
or the greater the obstruction offered to its diffusion throughout the
inflamed part. The intense pain resulting from inflammation of the
fascia or of the periosteum is thus explained, while an inflammation
of the loose connective tissue may be diffused over a wide area with
little or no pain. In the chronic varieties of inflammation, where the
exudation is but scanty, and its accumulation extended over a long
period of time, there may be no pain during the entire course of the
inflammation.

Swelling remains for consideration as the most important of the four
cardinal symptoms. Like the others, its presence is not absolutely
essential. It may exist at one time in the course of the inflammation,
and may be absent at another. Even a diminution in the size of an
organ may suggest the existence of an inflammation, for the yellow and
cirrhotic atrophies of the liver give evidence, respectively, of an
acute and chronic inflammation of this organ.

The swelling of an inflamed part is due to the presence of an
increased quantity of blood, and lymph, and to the exudation. These
constituents of the swelling are not of equal importance. Although the
quantity of blood in the part is increased, no considerable swelling
is produced, provided the flow of blood and lymph from the part be
unobstructed. The current of lymph through the larger lymphatics may
be greatly increased, yet a decided swelling be absent, unless there
is an obstruction to the passage of lymph from the inflamed region.

{42} The exudation is the most essential element of the swelling, and
our knowledge of its origin and fate includes the most important
features of the general pathology of the processes concerned.

The inflammatory exudation is represented by the accumulation, outside
the blood-vessels, of material previously within them. The prevailing
views concerning the manner of origin of this exudation, and its
relation to inflammatory processes, are essentially due to the
rediscovery by Cohnheim of the forgotten observation of Addison, that
white blood-corpuscles pass through the apparently intact walls of the
blood-vessels.

In the observation of the mesentery or other transparent part of a
suitable animal, the changes taking place in inflammation are, at the
outset, limited to the blood-vessels and their immediate vicinity. The
vessels become dilated and the rapidity of the flow within them is
soon diminished. In the veins particularly the white blood-corpuscles
separate in considerable numbers from the general current and line the
wall in constantly-increasing numbers, while the red corpuscles are
borne along the middle of the stream. The white corpuscles stagnate,
stick to the wall for a longer or shorter time, and often change their
place, while the red corpuscles are in constant and progressive
motion. In the capillaries a considerable number of white corpuscles
are found in contact with the wall, but numbers of red corpuscles are
associated with them. The formation of the exudation now begins by the
passage of white corpuscles through the apparently intact wall of the
veins and capillaries, especially of the former. Limited numbers,
under ordinary circumstances, of red corpuscles also make their way
through the walls of the capillaries. This is the phenomenon of
emigration, and is associated with the amoeboid movements of the white
corpuscles.

With the passage outward of the white and red corpuscles there is also
the effusion of liquid material. Both the liquid and solid
constituents continually escape and spread in all directions beyond
the wall, following the course of the least resistance. It is probable
that this course is defined by the pre-existing spaces within the
tissues of the part, the lymph-spaces. The exudation is more abundant
in parts richly provided with blood-vessels and in those containing
the larger spaces; it is diminished where the vessels are less
numerous or the surrounding parts more resistant, with smaller and
fewer lymph-spaces. The resulting swelling is the less when ready
opportunities for the diffusion and removal of the exudation by
lymphatics and veins are presented, and when the material appears upon
surfaces over which it may flow away.

The liquid portion of the exudation represents something more than the
transuded blood-serum, and a certain practical importance results from
the distinction drawn between an exudation and a transudation. Such a
distinction is especially called for when the inflammatory or
non-inflammatory origin of considerable quantities of fluid in the
larger cavities of the body is concerned. From a recent contribution
to our knowledge of this subject by Reuss[13] the following
information is derived: The percentage of albumen is always greater in
exudations than in transudations, and is more constant in the former
than in the latter. It increases with the severity of the
inflammation, being highest in the ichorous forms, less in the
purulent, and least in the serous exudations. When an {43}
inflammatory exudation is found to contain less albumen than usual,
the existence of a transudation with secondary inflammation is
suggested, or the exudation may have taken place in a hydraemic
individual. A sufficient number of exceptions are met with, however,
to interfere with the absolute nature of this test.

[Footnote 13: _Deutsches Archiv fur Klinische Medicin_, 1879, xxiv.
583.]

The coagulation of an inflammatory exudation apparently depends upon
the contained white blood-corpuscles; the more numerous (within
certain limits) these are in a serous exudation, the more abundant is
the formation of fibrin. The cellular element likewise is that which
in abundant liquid exudations characterizes them as purulent. Although
it is generally agreed that most of the corpuscles of pus are
emigrated white blood-corpuscles, it is not necessary to admit that
all are of this nature. The cells present in an inflamed part include
those pre-existing, as well as those which escape from the vessels.
The former are the wandering cells of the connective tissues, as well
as the fixed variety, the epithelial cells of the surface of a mucous
membrane in addition to the subjacent connective-tissue cells.
Amoeboid cells outside the blood-vessels have been seen to divide, and
it is possible that such duplication may serve as the method of
formation of a certain number of pus-corpuscles. The statements
concerning the proliferation of the fixed connective-tissue cells and
of epithelium are derived from appearances, and are interpretations of
these appearances, not observations of a process.

The changes taking place along the walls of the blood-vessels being
the feature of prime importance in the observation of the progress of
an inflammation, numerous investigators have directed their attention
to the determination of the nature of the changes in the vessel wall
by means of which the escape of the corpuscles is permitted. Arnold
represents the most strenuous advocates of the stomata theory,
according to which the leucocytes pass through canals normally
existing in the wall. By means of the silver method of staining, and
by injections of various insoluble pigments into the blood-current,
certain results are met with, which give color to the view that pores
and canals are present upon and in the walls of the vessels, analogous
to those found in the diaphragm. As the latter have been shown to be
in direct communication with the lymphatic system of tubes and spaces,
so the walls of the blood-vessels have been assumed to present similar
channels of communication.

The prevailing views at the present time are in favor of the
artificial nature of the stomata and pores in the walls of the
blood-vessels. An increased porosity of the vascular wall in
inflammation is necessary for the occurrence of the exudation, but
such porosity is regarded rather as a physical condition permitting an
observable filtration, and a filtration of solids as well as liquids.

In this connection reference should be made to the observation of
Winiwarter, who has demonstrated that colloid material, a solution of
gelatin, passes through the vascular wall in inflammation more
readily--_i.e._ under less pressure--than through the normal wall of
the blood-vessel.

The causes of inflammation are to be regarded as those which produce
an increased porosity of the vessel wall without causing its death,
for no exudation escapes from a dead vessel, its contents becoming
clotted.

These causes may act from without or from within, primarily affecting
{44} the tissues outside the vessels, or exerting their action, at the
outset, upon the wall itself. The usual histological relation of
vessels and surrounding tissues is such that both are simultaneously
affected. The occurrence of an inflammation in non-vascular parts,
however, as the cornea, from irritation of its centre, the part
farthest removed from the surrounding blood-vessels, shows that the
affection of the vessels may be indirect as well as direct. This
indirect action is to be regarded as taking place through the agency
of nerves or through that of the nutritive currents. That nervous
influence alone does not suffice to transmit the effect of an applied
cause is apparent from the absence of inflammation of the cornea which
has become anaesthetized by section of the trigeminus nerve. With the
protection of the cornea from external irritation there is an absence
of inflammation.

The consideration of the final symptom of inflammation, the
disturbance of function, which has been added in recent times, belongs
to special rather than general pathology. It varies according to the
seat of the inflammation, the disturbed function of the brain or heart
differing from that of the liver or kidney. The clinical importance of
this symptom of inflammation is greater than of all the rest, as it is
the one whose presence is constant and indispensable.

An inflammation may exist, as already stated, without heat, redness,
or pain. The swelling may escape observation from the limited quantity
of the exudation and other causative agents, or from the
inaccessibility of the inflamed part to physical examination. The
disturbance of function, however, becomes early apparent, and is
present throughout the course of the inflammation. A knowledge of its
nature enables the seat of the latter to be recognized, and its
variations furnish a desired test of the efficiency of therapeutic
agents.

       *       *       *       *       *

The causes of inflammation may be divided into the traumatic, toxic,
parasitic, infectious, dyscrasic or constitutional, and trophic.

The traumatic causes are those which act mechanically, producing an
injury to tissues by pressure, crushing, tearing, stretching, and the
like. Others represent modifications in temperature, thermic agencies,
and include extremes of cold as well as of heat. The chemicals whose
action is direct, as caustic, include a third variety of the traumatic
causes. Such chemicals are applied to surfaces, cutaneous or mucous,
and comprise the active element producing the perforating ulcer of the
stomach and duodenum, as well as such substances as potash or
sulphuric acid which may have been swallowed intentionally or
accidentally.

The toxic group of causes is closely allied to the chemical variety of
the traumatic agencies. It includes chemicals whose action is
indirect, through absorption in a diluted form rather than from direct
application in a concentrated condition. Such chemicals are derived
from without, as arsenic, phosphorus, and antimony; or may be formed
within the body, and the latter include the chemical products of
putrefactive changes--in the urine, for instance--and, with
considerable probability, certain of the active agents of
blood-poisoning in septic diseases. It is not unlikely that some of
the inflammatory affections met with among the so-called
constitutional diseases, as rheumatism and gout, may owe their origin
to the production of chemical substances within the body, excessive in
quantity if not changed in quality.

{45} The parasitic causes of inflammation are both animal and
vegetable, and act upon the surfaces of the body or within its
deeply-seated parts. Some of the animal parasites act locally at their
place of entrance, while others produce but slight disturbances in
this region, their effects usually resulting from the transfer of
their offspring to remote parts of the body. The vegetable parasites
are for the most part the various fungi, which act locally upon the
skin or on those transitional surfaces lying between skin and mucous
membrane. The resulting parasitic inflammations are known as favus,
sycosis, ringworm, thrush, etc. The border-line between such parasitic
diseases and those included among the infective diseases is somewhat
arbitrarily drawn. Parasites in the limited sense act chiefly as
foreign bodies, while the effect of minute vegetable organisms is
rather that of ferments, in virtue of their products. Such a
distinction is of relative value merely, as the micrococci and
bacteria are capable of acting in other ways than by the production of
septic material.

The infectious causes of inflammation are for the most part parasitic
in their nature, although the discovery and identification of the
parasite are in most of these inflammations assumed rather than
demonstrated. The relation of the anthrax bacillus to malignant
pustule no longer admits of a doubt, mainly in consequence of the
researches of Koch. This investigator has been enabled to establish a
definite etiological relation between the septicaemia of certain
animals and accompanying minute vegetable organisms. His recent
discovery of the bacillus of tuberculosis definitely removes the
tubercular process from the group of dyscrasic or constitutional
affections to that of the infective diseases. The constant presence of
minute organisms in relapsing fever, leprosy, malaria, typhoid fever,
diphtheria, erysipelas, and numerous other affections associated with,
if not characterized by, inflammatory conditions, renders extremely
probable the closest pathological relation between such diseases and a
microscopic organism. That an inflammatory process may be regarded of
infectious origin, it is necessary, according to Koch,[14] that a
characteristic organism should be found in all cases of the disease,
and in such numbers and distribution as to account for all the
phenomena of the disease in question.

[Footnote 14: _Untersuchungen uber die Aetiologie der
Wundinfectionskrankheiten_, 1878, 27.]

These organisms may act in virtue of their growth and the consequent
demand for oxygen, as seems probable in certain cases of malignant
pustule, where the affected individual dies with symptoms of asphyxia.
Their operation may also be like that of ferments, which produce
chemical material whose effect may be remote from the immediate
presence of the minute organism. They may likewise, in connection with
their colonization in various parts of the body, act more immediately
upon the walls of the blood-vessels, and produce that increased
porosity which is so essential a factor in inflammation.

The discovery of the immediate cause of the various infective
diseases, as measles, scarlatina, variola, cholera, dysentery, mumps,
whooping cough, cerebro-spinal meningitis, and numerous other epidemic
and endemic affections, still remains a question for the future. The
constant association of microbia with any or all of such diseases is
but one fact in connection with them, and such a discovery is to be
regarded merely as a step forward, to be followed by others, each of
which represents not only an advance, but confirms the position
attained.

{46} The dyscrasic or constitutional causes of inflammation are those
which, though long established, appear less demanded as our knowledge
advances. Regarded as the result of an alteration in the composition
of the blood, it is obvious that such changes may arise from the
introduction, from without, of wholly foreign material. The dyscrasia
may also represent modifications in the relative proportion of the
normal constituents of the blood. In the former series are included
what, for the most part, have already been referred to under the toxic
and infectious causes of inflammation. The dyscrasiae from lead,
alcohol, and the like belong to this series. Still more important are
the poisons, the virus of tuberculosis and scrofula, of leprosy and
syphilis. The dyscrasiae known as anaemia, leucaemia, uraemia,
icterus, and diabetes are to be regarded less as inflammatory causes
than as predisposing conditions which favor the action of other groups
of causes.

The trophic causes of inflammation are those whose action is supposed
to take place through the influence of nerves. Although, as has
already been stated, a faulty innervation of tissues is an important
element in favoring the action of various inflammatory causes, there
remain certain forms of inflammation where the disturbance of nervous
action seems to be the essential feature. The occurrence of an acute
peripheral gangrene soon after certain traumatic or inflammatory
lesions of the brain or spinal cord, of articular inflammation
following chronic affections of the cerebro-spinal axis, are instances
in point. The origin and distribution of herpes zoster, the occurrence
of sympathetic ophthalmia and symmetrical gangrene, suggest a
predominant disturbance of innervation as the exciting cause. At the
same time, it is desirable to call attention to the recent
observations of MacGillavray, Leber, and others,[15] which suggest
that a sympathetic ophthalmia is due to the extension of a septic
choroiditis along the lymph-spaces of the optic nerve. It is further
apparent that in certain so-called trophic inflammations, as the
pneumonia after section of the pneumogastric, and the inflammation of
the eye following paralysis of the trigeminus, the paralysis of the
nerve is a remote, rather than an immediate cause, of the
inflammation. There still remain, however, a number of localized
inflammations whose origin is so intimately connected with nervous
disturbances as to demand, for the present at least, a corresponding
classification.

[Footnote 15: Wadsworth's "Report of Recent Progress in
Ophthalmology," _Boston Medical and Surgical Journal_, 1882, cvi.
517.]

The course of an inflammation is often indicated by the predominance
of certain symptoms, which, for the most part, indicate a condition of
the individual acted upon rather than a peculiarity of the cause. The
sthenic inflammations take place in robust individuals with powerful
hearts and an abundant supply of blood. In such persons a strong
pulse, high fever, and an injection of the superficial blood-vessels
suggested, in former times, the necessity of bloodletting as the
essential therapeutic agent. The sthenic form of inflammation was most
commonly associated with pneumonia, where the obstruction to the
passage of blood through the lungs was an important cause of the
superficial injection of the blood-vessels.

The asthenic inflammations, on the contrary, are those occurring in
feeble individuals, debilitated in consequence of pre-existing
disease, exposure, or habits. A weak heart, low febrile temperature,
and {47} superficial pallor, characterize the asthenic inflammations,
which show a frequent tendency to become localized in the more
dependent parts of the body, the force of the circulation being too
feeble to overcome the effect of gravitation.

In the typhoidal inflammations are associated those symptoms which are
so prominent in the severe varieties of typhoid fever. These are the
predominant symptoms: hebetude or low, muttering delirium, picking at
the bed-clothes, involuntary evacuations, stertor, and the like. The
nervous disturbances are associated with a feeble pulse and a dusky
hue of the skin.

The constituents of an inflammatory exudation are frequently used as a
basis of classification, and characterize the inflammation from the
anatomical point of view. As the exudation is complex in its
composition, the predominant element is made use of to designate the
variety, and in doubtful cases a combined adjective indicates the
presence of the two most abundant constituents. As the exudation is
directly derived from the blood and contains serum in addition to
white and red corpuscles, the serous, purulent, and hemorrhagic
varieties of exudation naturally arise. The fibrinous and diphtheritic
inflammations relate to the presence of membranes or false membranes.
Finally, there are the productive inflammations, resulting in the new
formation of tissue, and the destructive inflammations, where losses
of substance occur.

Serous inflammations are most frequent in those parts of the body
where the structure contains the largest lymph-spaces. The so-called
serous cavities of the body offer the most favorable opportunities for
the accumulation, as well as for the exudation, of the inflammatory
product; then follow the regions of the larger lymph-spaces, according
to the size and number of the latter.

The serous inflammations may also arise from the epithelial coverings
of the body, as the cutaneous, alimentary, and respiratory surfaces.
The serous exudations of the skin are those present in vesicles,
blisters, or bullae, which owe their limitation to the resistance
offered to the spreading of the liquid inflammatory product by the
coherent epidermis. Serous inflammations of the alimentary canal may
assume a vesicular character, although, from the structure of its
mucous membrane and the macerating influence of its contents, the
vesicles are apt to be of an extremely transitory character.

The more important serous inflammations of the intestines are those
manifested by profuse watery evacuations, the extreme form of which is
to be found in cholera.

Serous inflammation of the lungs accompanies the more severe forms,
and usually represents but a limited and circumscribed affection,
associated with more abundant cellular and fibrinous products.

Serous inflammations of the peritoneum, pleura, pericardium, tunica
vaginalis, and central ventricles often give rise to the presence of
enormous quantities of fluid, whose partial removal from many of the
cavities concerned by operative measures frequently represents a most
beneficial result of treatment.

The smaller lymph-spaces of the connective tissue in various parts of
the body are the frequent seat of the inflammatory oedema, so called,
whose presence is an important indication of the direction assumed by
a {48} spreading inflammation, as well as a suggestion of the frequent
virulence of its cause.

In general, the serous inflammations are to be regarded as less severe
than other varieties, or as representing an early stage of what later
may be otherwise characterized by a change in the nature of the
products.

The purulent variety of inflammation is present when the exudation is
abundantly cellular. As has already been stated, such cells are, for
the most part, white blood-corpuscles. The purulent exudation, like
the serous variety, may appear either on surfaces, when the term
secretion is applied, or within the lymph-spaces of the connective
tissue over a considerable space, when the pus is said to be
infiltrated. When the infiltration is more circumscribed and the walls
of the affected lymph-spaces are destroyed, so that adjoining cavities
are thrown into larger holes, an abscess is present, from whose wall
pus is constantly derived, while the inflammation is progressive.

The attention of the surgeon, in particular, has been directed to the
isolation of the immediate cause of suppurative inflammation, and the
modern, antiseptic, treatment of wounds is essentially based upon the
view of the infectious origin of pus. The frequent presence of
microbia in purulent exudation where no precautions are taken to
exclude their admission, and their frequent absence or presence in
minute quantities where such precautions are taken, have suggested
that through their influence an inflammatory exudation is likely, if
not actually compelled, to become purulent.

Whether the microbia or their products are the cause of most
suppurative inflammations may be regarded as an open question. It is
generally admitted, however, that, as a rule, an inflammation becomes
purulent in consequence of the presence of an infective agent; in
other words, that most pus is of an infectious origin and possesses
infectious attributes. The labors of Lister in insisting upon the
exclusion of all possible putrefactive agencies in the treatment of
wounds have met with universal approval, and the basis of his
treatment remains fixed, although different methods have been devised
for its enforcement. His researches, and those stimulated by his work,
have resulted in the establishment of principles which affect the
whole field of theoretical as well as practical medicine.

Although most pus may be considered as due to the action of a virus
introduced from without, and capable of indefinite progressive
increase within the body, all pus is not to be regarded as of
infectious origin. There are pyrogenetic agencies, like petroleum,
turpentine, and croton oil, which, introduced into the body, produce
suppurative inflammation without the association of microbia.

A bland pus is usually in a state of beginning putrescence, so that it
is only relatively bland, and acquires extreme virulence when long
exposed to putrefactive agencies. It is possible that those agencies
producing an ichorous pus are the same or different from those present
in bland pus. The ichorous exudation contains less corpuscles than
bland pus, is more fluid, less opaque, strongly alkaline, of a
greenish color, and of offensive odor.

In hemorrhagic inflammation the exudation contains large numbers of
red blood-corpuscles. The occurrence of this form is sometimes
associated {49} with peculiarities of the cause, as is obvious from
the epidemics of hemorrhagic small-pox, measles, scarlatina, and
cerebro-spinal meningitis. It is also associated with peculiarities of
the individual, as in such epidemics all cases are not equally
hemorrhagic, and in scurvy the hemorrhages are attributable to the
abnormal conditions to which the sufferers are exposed. Hemorrhagic
exudations are also met with in those inflammations of serous surfaces
accompanying the outcropping of tubercular and cancerous or
sarcomatous growths. In all cases a hemorrhagic exudation represents a
grave complication, and when found in serous cavities has a certain
diagnostic, as well as prognostic, importance.

Fibrinous inflammations are characterized by the presence in the
exudation of considerable quantities of fibrin. As the prevailing
theory of the formation of fibrin demands fibrino-plastic as well as
fibrinogenous material, both are to be sought for in the exudation.
The latter is present in the liquid portion of the exudation; the
existence of the former, as well as that of the ferment, is dependent
upon the presence of the white blood-corpuscles. The more numerous
these, within certain limits, the more abundant the formation of
fibrin. As their death appears essential for the fibrinous
coagulation, the latter is most constantly met with in those parts of
the body where the white blood-corpuscles are quickest separated from
influences favoring their life. The farther removed they are from the
blood-vessels, the more likely is their early death. Fibrinous
exudations are therefore frequent and abundant in cellular and serous
(sero-cellular) inflammation of the great serous cavities of the body.
The clotted fibrin appears as false membrane lying upon the serous
surface, either smooth or rough, tripe-like, or as villosities
projecting above the surface, and again as bands, fibrinous adhesions,
stretching across the cavity and uniting opposed surfaces.

The frequent occurrence of fibrinous exudations on the mucous
membranes of the larynx and trachea, accompanied by the suffocative
symptoms known as croup, has led to the use of the term croupous
inflammation as synonymous with fibrinous inflammation, and its
application to various parts of the body where croupous--_i.e._
suffocative--symptoms are not in question. Croupous inflammation, when
used, is to be considered as an anatomical term, indicating merely the
production of fibrin, and, for the avoidance of confusion, it is
preferable to substitute fibrinous for croupous when such
inflammations are described.

The disease, croup, it is well known, may exist without a
croupous--that is, fibrinous--inflammation, as is familiarly
recognized in the constant use of the terms spasmodic, membranous, and
diphtheritic croup.

Fibrinous inflammation of the mucous membrane of the larger
air-passages is much more frequently met with than that of mucous
membranes elsewhere, as of the intestines, uterus, and bladder. The
pseudo-membranous inflammations of the latter tracts are more commonly
the result of the catarrhal and diphtheritic varieties than of the
fibrinous form. Fibrinous exudations on mucous surfaces, according to
Weigert, can only take place when the epithelium is destroyed. Hence
those causes which give rise to the destruction or detachment of the
epithelium are alone capable of producing a fibrinous inflammation of
mucous membranes, and a fibrinous laryngitis, trachitis, and
bronchitis may result from {50} the local application of such
irritants as steam or ammonia, as well as occur in the diseases croup
and diphtheria.

Fibrinous exudations may also be present within tissues, especially in
those whose meshes are wide, provided the essential elements of
coagulation are present. The coagulative necrosis of various organs,
to be more fully mentioned hereafter, is closely allied to fibrinous
clotting, the fibrino-plastic element being derived from the death of
the parenchymatous cells of the part.

In the existence of a fibrinous pneumonia the conditions are somewhat
analogous to those present in the fibrinous inflammation of serous
surfaces and of the areolar connective tissue. There is present an
abundantly cellular exudation, held in the place of its origin, the
cells undergoing rapid death and surrounded by a wall whose
superficial cells resemble in structure, if not in origin, the
endothelial cells lining the smaller lymph-spaces of connective
tissue, as well as the larger cavities within the same, known as
serous cavities.

The diphtheritic inflammation is no more to be confounded with the
disease diphtheria than is the fibrinous inflammation with the disease
croup. Although diphtheria owes its name to the frequent presence of
an apparent membrane, it may be said that the latter is not essential
to the existence of the former. Diphtheria, like croup, is an
affection in which various exudations may be present, and the
anatomical product alone does not suffice in all instances for the
recognition of the disease. In croup there may be a swollen mucous
membrane, with a slight superficial mucous exudation, or a more
abundant exudation of desquamated epithelium and mucus, as well as a
fibrinous false membrane. In diphtheria the same varieties of
exudation may occur, and in addition the diphtheritic exudation may
also be present. The latter, however, is not limited to the disease
diphtheria, for its presence is apparent in other mucous membranes
than that of the air-passages, and in the pharyngeal mucous membrane
in other diseases than diphtheria. A diphtheritic conjunctivitis,
enteritis, cystitis, and endometritis are recognized. The cutaneous
surfaces of the body may also furnish a diphtheritic exudation. The
diphtheritic inflammations of wounds and of variolous eruptions are
instances in point.

The characteristics of a diphtheritic inflammation are the presence
within the tissues of a clotted exudation, which is associated with a
defined swelling and death of the part. The exudation contains not
only dead leucocytes and interlacing fibres, but is also provided with
abundant granular material, much of which presents the well-known
peculiarities of microscopic organisms. The apparent false membrane is
thus dead, infiltrated tissue, which may be torn away from the
continuous unaffected tissue, leaving a raw, rough surface, but not
peeled from a comparatively smooth surface, as in other forms of
pseudo-membranous inflammation.

The frequent association of a superficial false membrane,
corresponding in area with that of the deeper-seated changes, in which
cells and fibres may be present, is to be recognized. The diphtheritic
process, however, is localized within, and not upon, the tissues
affected. The diphtheritic exudation represents a local death, a
necrosis, of the part concerned, and the result has frequently been
compared with the death consequent upon the action of a caustic.

{51} The immediate cause of a diphtheritic inflammation is now
generally attributed to the action of microbia which enter the tissue
from without, and in their growth beneath the surface produce not only
the local, but also the remote, constitutional disturbances which are
associated with a diphtheritic inflammation. The investigations of
Wood and Formad[16] point to ordinary putrefactive organisms as a
sufficient cause for the diphtheritic inflammation of diphtheria,
while other observers demand a specific organism as the exciting
cause. The occurrence of diphtheritic inflammations in various parts
of the body, in regions, as the intestine, where putrefactive
processes are constantly present, and in the bladder and uterus, where
the phenomena of putrefaction are often associated with diphtheritic
inflammation, suggest the efficacy of ordinary putrefactive agencies
in producing the latter. As all microbia found in putrefaction are not
alike, and as the properties of certain, differ from those of others,
and as our knowledge of the effects of all is but fragmentary, the
characteristics of specific germs for a diphtheritic inflammation of
one part of the body, or of all parts of the same, must still be
regarded as not proven.

[Footnote 16: _Research on Diphtheria for the National Board of
Health_, 1880, Supplement No. 7.]

Productive inflammations are those which result in the new formation
of tissues. One of the frequent products of inflammation is fibrous
tissue, which, at first abundantly cellular, later becomes more
vascular, and is finally transformed into a tissue whose fibres
predominate over its cells. This formation of a cicatricial tissue
demands further recognition when the termination of inflammation is
considered.

In a more limited sense certain inflammations are called productive
when multiple circumscribed new formations, as cancer, sarcoma,
tubercle, and the like, arise in connection with the ordinary products
of inflammation. Such new formations are of frequent occurrence in
serous membranes, and a tuberculous pericarditis or a cancerous
peritonitis, indicates that a growth of tubercles or cancerous nodules
has taken place, in addition to a more or less abundant exudation with
various proportions of serum fibrin and cells. This association of
ordinary and transitory inflammatory products with the formation of
more permanent tissues may be found within organs as well as upon
surfaces. A tubercular arachnitis or lepto-meningitis presents the
various products of an inflammation of the pia mater with an abundant
formation of tubercles. In like manner, a tubercular pneumonia, or a
tubercular nephritis suggests an association of neoplastic growth and
inflammation, in the lung and kidney. Such a relation offers a basis
for the theory in favor of the inflammatory origin of tumors, and is,
in part at least, a cause for the frequent consideration of tubercles
as mere inflammatory products, wholly cellular or cellular and
fibrous, subject to the same modifications as take place during the
course of ordinary inflammations.

Even if tuberculous and scrofulous inflammations are regarded as
inflammatory processes, modified by a specific cause and by
peculiarities of the individual, the cancerous and sarcomatous
inflammations are still to be considered as representing an
association of inflammatory disturbances and specific new formations,
the cause of the latter not being the cause of the former. As ordinary
inflammations of the regions concerned may take place in the absence
of the neoplasms, so may the {52} specific growth appear in the same
regions without anatomical or clinical evidence of inflammation.

The classification of inflammation as to its products is supplemented
by distinctions drawn with reference to the seat. The exudations may
be superficial or deep-seated; they may lie within the cells,
parenchyma, of an organ, or within the interstitial tissue of the
same.

The product of superficial inflammations may lie on the surface, as in
the case of inflamed mucous membranes, or immediately below the
surface, as in numerous cutaneous inflammations, of which erysipelas
may serve as the type. The term catarrhal, applied to superficial
inflammations, carries with it the idea of displacement, flowing, of
the exudation. The product of a catarrhal inflammation must be largely
liquid, that such a displacement may readily take place, and the
catarrhal exudation is chiefly composed of an excess of those elements
which are present in the normal, physiological secretion from the
membrane concerned. Mucus therefore represents a frequent constituent
of the catarrhal exudation, and mucous as well as muco-purulent
catarrhs of the gastro-intestinal, bronchial, genito-urinary, and
other mucous membranes are recognized. The catarrhal inflammation of
the respective membranes usually represents the mildest form, as it
demands an intact epithelium, and a ready removal of the inflammatory
product.

As the cause of a catarrhal inflammation may occasion a destruction of
the epithelium or a necrosis of the mucous membrane, the frequent
association of catarrhal with fibrinous or diphtheritic inflammations
is obvious. In such cases the clinical importance of the latter
varieties gives them the precedence in the designation of the
inflammation. The retention of the catarrhal products is the frequent
cause of permanent disturbances of a more or less serious nature.
These result in part from the mechanical obstruction offered to the
function of parts beyond the seat of obstruction, as pulmonary
atelectasis; and in part from the changes taking place in the retained
product. Purulent otitis media with its dangerous or fatal results,
and gangrene of the lung terminating in septic pleurisy, are not
infrequent instances of severe disturbances from putrefaction of the
retained products of a primarily catarrhal inflammation. A cheesy
degeneration of the catarrhal cells leads to a surrounding fibrous, or
destructive, inflammation, with a corresponding diminution in the
function of the organ affected.

Of the deep-seated varieties of inflammation, that requiring special
mention is the phlegmonous form. This runs its course within the less
dense fibrous tissue known as the areolar or cellular tissue. The term
cellulitis is usually employed by English writers to indicate the seat
and nature of the process, and although the use of the term cellular
tissue is rapidly becoming obsolete, the convenience of cellulitis
favors the retention of the latter name.

The exudation lies within the larger lymph-spaces, and is therefore
sometimes designated as the result of a lymphangitis, the deep-seated,
wider lymph-spaces being concerned rather than those more superficial.
Certain forms of phlegmonous inflammation are of decidedly infectious
origin, and, when seated subcutaneously, are known as phlegmonous
erysipelas, being thus distinguished from the simple erysipelas, whose
seat is defined by the small superficial lymph-spaces of the skin.

{53} Infective forms of cellulitis are also frequently met with in the
loose, sub-peritoneal tissue of the pelvis. The infectious element
usually proceeds from the uterus, and excites the malignant oedema of
the broad ligament, the septic parametritis, or the pelvic cellulitis,
according as the lymph-spaces inflamed lie nearer the fundus or
cervix, and as the direction of the current is upward toward the
spine, or outward toward the sub-peritoneal lymphatics of the pelvic
wall.

Parenchymatous inflammation is present when the exudation is taken
into the cells of an organ, or when the changes dependent upon
inflammation of an organ take place within its functionally important
cells. Virchow originally used the term parenchymatous inflammation in
contradistinction to secretory inflammation, the changes in the former
occurring within the elements of the tissues, while in the latter the
exudation made its appearance on the surface of the organ.

Parenchymatous inflammation is manifested by a degeneration of the
cells affected. This may terminate in their destruction through the
conversion of their protoplasm into fat-drops, fatty degeneration;
although more frequently a simple accumulation of albuminoid granules
(granular degeneration) occurs. The latter represents a transitory
condition, from which a return to the normal state readily takes
place. This form of inflammation is met with in those organs which
present a sharply-defined contrast between the functionally important
cells and the connective tissue which surrounds them. The liver,
kidneys, heart, spleen, pancreas, and glands in general, are
consequently the most frequent seat of parenchymatous inflammation.

Opposed to this variety is the interstitial inflammation. The
exudation of the latter remains within the connective-tissue framework
of the organ. It is essentially cellular in character, and the number
of cells is comparatively small. With their presence and the
possibility of their nutrition a permanent increase in the quantity of
the fibrous tissue of the organ is permitted. This becomes relatively
greater in the course of time, and the parenchymatous cells become
degenerated and absorbed. Interstitial inflammations are likely to
become chronic in character, and, from the outset, are usually
associated with parenchymatous changes.

An important clinical distinction is drawn with reference to the
duration of an inflammation. Acute inflammations are those whose
course is rapid, whose progress is associated with graver disturbances
of function, and with a greater prominence of the cardinal symptoms.
The chronic forms occupy more time in their progress, the functional
disturbances, though severe, are injurious more from their protracted
persistence, than their temporary violence, while redness, swelling,
heat, and pain are symptoms of trifling prominence.

The exudation in acute inflammation, if recovery takes place, is
rapidly removed from the place of its origin, while in the chronic
variety it tends to become a part of the region in which it lies, or,
if removed, slowly disappears, and may be constantly replaced. Acute
inflammations may become chronic, and the chronic variety is liable to
acute exacerbations.

The distinction between acute and chronic inflammations is essentially
one of convenience, and, when considered from the anatomical point of
view, relates rather to the persistence of the results. These may be
{54} present as a variously modified exudation or as a degenerated
condition of the parenchyma of the organ or tissue affected.

Inflammation terminates in resolution, production, or destruction.

For resolution to occur it is necessary that the causes of
inflammation cease to act, either by their removal or their isolation,
and that their results be removed. With the removal of the results
there is often associated the removal of the cause. That such may take
place it is necessary that the function of the vessel walls be so
restored that the exudation ceases to escape. Inflammatory products
already outside the vessels, if present on surfaces with external
outlets, are carried along in the course of the excretions. If they
lie within the cavities of the body not opening externally, their
removal is accomplished through the medium of the circulating lymph
and blood, by absorption. The liquid portion of the exudation becomes
a part of the circulating fluids of the body. The fibrin is converted
into a granular detritus, which eventually disappears from the place
of its formation. The leucocytes may return to the blood-vessels or
enter the lymphatics; the latter course probably being the one taken
by the larger number of the corpuscles. Many undergo a fatty
degeneration, and as they lie in lymph-spaces their conversion into an
emulsion permits a removal of the mechanical obstruction to the flow
of lymph through the spaces in which they were accumulated. The red
blood-corpuscles are destroyed, their pigment being dissolved by the
surrounding fluid and removed in the course of the circulation and
excretions, or it becomes transformed into granules or crystals, which
may remain in the place of their formation, or be transferred, within
amoeboid cells, to remote parts of the body.

When the exudation is abundant, as in the great lymph-sacs of the
body--the several serous cavities--and especially when the openings in
the walls of these sacs are obstructed or the currents within them are
feeble, absorption takes place with great difficulty, and demands a
long interval of time. The fibrinous and cellular portion of such an
exudation frequently becomes converted into a caseous mass, from a
partial fatty degeneration and inspissation. This mass becomes
isolated from the cavity in which it lies, usually at the most
dependent portion, by the formation of a capsule of connective tissue.
It may subsequently become infiltrated with lime salts, calcified, and
thus remain comparatively inert throughout the life of the individual.

The productive termination of inflammation is manifested by the new
formation of connective tissue. This tissue is variously designated,
as the inflammatory process is limited to the surfaces of the body
exposed to the air, or the surfaces of cavities and organs, or as it
lies within organs or the deep-seated parts of the body. In numerous
instances it becomes a permanent constituent of the body, and, as time
is usually essential for its formation, its occurrence is indicative
of a chronic, rather than an acute inflammation. Certain chronic
inflammations are progressive in character, the production of
connective tissue being continuous, with perhaps occasional
intermissions, as in the chronic interstitial inflammations of organs
and tissues. The new-formed tissue, which at the outset is rich in
cells, becomes in time more fibrous, and associated with this change
in structure is a physical modification, manifested by its shrinkage.
This new formation may fill a gap resulting from the destruction of
tissue in {55} the progress of an inflammation, when it is present as
cicatricial tissue--the scar which is usually met with upon the
surfaces of the body or of certain of its organs. When opposed
surfaces are united by the new-formed tissue, the term adhesion is
applied; the adhesions being present as fibrous bands, cords, or
membranes. The pericardial milk-spots and thickenings, the tendinous
or semi-cartilaginous, indurated patches of serous membranes and of
the intima of arteries, are all regarded as manifestations of a
chronic inflammation of these tissues. With the localization of the
inflammation in the outer walls of the bronchi and blood-vessels a
thickening of the external sheath results, called a peri-bronchitis,
arteritis, or phlebitis, as the case may be.

The new formation of blood-vessels is essential for the production and
preservation of this connective tissue, and both arise from
pre-existing tissues. Pus-corpuscles represent the simple cellular
product of an inflammation, and their existence is but transitory.
With the new formation of blood-vessels imbedded in abundant cells
there exists a granulation-tissue, likewise transitory, but out of
which arises the permanent fibrous tissue. The question is still
mooted as to the part played by exuded white blood-corpuscles in the
production of the permanent results of inflammation. It is generally
conceded, especially since the observations of Ziegler, that they are
capable of transformation into lasting constituents of tissue, into
blood-vessels as well as into cells and fibres. Whether all the
resulting permanent products of inflammation are dependent upon their
activity, or whether the pre-existing fixed elements participate, is
still to be considered undecided.

What, at present, appears most probable is, that from exuded
leucocytes there arise, in the course of several days, larger
cells--epithelioid or endothelioid--which are eventually associated
with still larger cells, more irregular in shape, and provided with
projecting filaments, giant-cells. Both varieties may result from the
enlargement of leucocytes by fusion or by the assimilation of
nutriment. The epithelioid cells eventually become fusiform or
stellate, and their projections, as well as those of many of the
giant-cells, become fibrillated. The fibrils of adjoining cells,
becoming united, are thus transformed into a meshwork of fibrous
bundles enclosing irregular spaces, while the nuclei of the cells,
with the immediately surrounding protoplasm, remain upon these bundles
as the permanent cells of the new-formed tissue. The blood-vessels
arise from pre-existing vessels, chiefly capillaries, and probably are
also formed from the cells present in the exudation. The former method
is indicated by the projection of solid sprouts from the wall of a
capillary, which may unite, forming arches, and communicate with
sprouts from neighboring capillaries, thus forming bridges. Both
arches and bridges then become hollowed and admit the circulating
blood. Ziegler maintains that the projections of the larger
epithelioid cells and giant-cells become elongated, and eventually
fused with capillaries, or the projections from capillaries. When this
fusion is accomplished the cells become hollowed, their cavities
communicating with those of the blood-vessels. These epithelioid
cells, whose formation and transformation are of such importance in
the history of productive inflammation, are designated by Ziegler as
formative cells, and are frequently derived from the exuded white
blood-corpuscles, though not identical with them.

{56} The inflammations not terminating in resolution or production,
end in the destruction of the part. This result occurs when the
nutrition of the inflamed territory is so diminished, by the changes
in and around the vessels, as to become insufficient for its
preservation. As the nutriment is derived through the blood-vessels,
the more complete and the more permanent the stagnation in them the
more likely is death to result. This event also depends upon the
quantity and quality of the exudation. The more abundantly cellular
the latter, the more likely is an abscess or ulcer to result.

As most abundantly cellular exudations are considered to be dependent
upon the presence of putrefactive agencies, those inflammations of a
predominant putrid character (gangrenous inflammations) are those
terminating in destruction. The dead product is present as a slough or
sequestrum, when dead soft or hard tissues are detached, entire or in
part, from the living; or as a granular detritus contained in a more
or less abundant liquid. The inflammatory process producing the slough
and sequestrum is characterized as a gangrenous inflammation of soft
parts or a caries of bone, while the process resulting in the
formation of the granular detritus, and which has no necessary
connection with putrefactive agencies, is called a softening, from the
physical condition of its result.


Thrombosis and Embolism.

A blood-clot formed within a blood-vessel during life is called a
thrombus. The entire process of which the thrombus is the essential
element is designated thrombosis.

These terms were introduced by Virchow[17] to avoid the confusion
which resulted from regarding the process and result as synonymous
with inflammation of the vessel. All writers, even at present, do not
adhere to this strictness of meaning. For a thrombus of the vulva
indicates a clot of extravasated blood within the connective tissue of
the labium; in like manner, a vaginal thrombus is the effused and
clotted blood in the loose connective tissue surrounding the vagina.
These exceptions are gradually disappearing, and the word haematoma,
tumor composed of clotted blood, is being substituted in both
instances. A cancerous thrombus represents a mass of cancerous tissue
whose growth is extended along the course of a vessel, its wall having
been penetrated. In general, however, the term thrombus, unless
otherwise qualified, is used as first stated.

[Footnote 17: _Handbuch der Speciellen Pathologie und Therapie_,
Erlangen, 1854, i. 159.]

Although thrombosis is commonly a morbid process, it is not uniformly
so. Its physiological significance is illustrated by the part it takes
in the closure of the umbilical and uterine vessels, after childbirth.
The surgeon makes use of it in his efforts to overcome certain of the
ill effects of amputation, and to accomplish a cure of such local
diseases as aneurism, where it is deemed important to diminish the
supply of blood.

The thrombus being a blood-clot, it is composed, like the latter, of
fibrin and blood-corpuscles. It is presumable that the fibrinous part
of a thrombus owes its origin to the same conditions which determine
the presence of fibrin in blood removed from the vessels during life
or in that within the vessels after death.

{57} According to A. Schmidt,[18] the blood and other fluids, in which
clotted fibrin makes its appearance, contain two generators, called
fibrino-plastic and fibrinogenous. The former is considered to be
paraglobulin, a substance contained mainly in the white
blood-corpuscles, while the fibrinogenous generator is held in
solution in the plasma of the blood. When these materials are acted
upon by a third, the fibrin ferment, clotting takes place and fibrin
is formed. It is thought that the ferment is intimately connected with
the white blood-corpuscles, for with the microscope coagulation is
seen to advance as these become destroyed, and where the leucocytes
are most abundant, there coagulation advances most rapidly. The
elements of clotted fibrin are always present in circulating blood,
but Brucke has shown that blood remains fluid, under ordinary
circumstances, because of its constant contact with the normal
vascular wall.

[Footnote 18: Rollett, _Hermann's Handbuch der Physiologie_, Leipzig,
1880, iv. 1, 114.]

The general causes of thrombosis are those which produce an abnormal
condition of the endothelium, a rapid destruction of the white
blood-corpuscles, or a stagnation of the blood. With the presence of
one of these causes there is often conjoined another, and the
conditions under which they are present are conveniently used in the
classification of thrombi.

Although stagnation of the blood is often an important immediate cause
of its coagulation, it is apparent, from the investigations of
Durante[19] and others, that stagnant blood clots in the living
vessels only when their endothelium is in an abnormal condition. With
the co-existence of abnormal endothelium and stagnant blood, thrombi
form with greater frequency and become more voluminous in a given
interval of time.

[Footnote 19: _Wiener Medizinische Jahrbucher_, 1871, 321.]

The importance of the death of white blood-corpuscles in the formation
of thrombi is generally admitted, and is especially insisted upon by
Weigert. According to the observations of Zahn, the nucleus of certain
thrombi is the result of the death of these leucocytes and their
accumulation upon an altered intima. The experiments of Naunyn,
Kohler, and others show that a thrombus may be rapidly produced by the
injection into the blood of fibrino-plastic substances, and of those
through which free haemoglobin is admitted into the circulation. The
former may be expressed from a fresh blood-clot; the latter may be
obtained by thawing frozen blood, or by injecting such material
(bile-acids, for instance) into the circulating blood as rapidly
destroys the red blood-corpuscles. Although Weigert lays special
stress upon the destruction of white blood-corpuscles in the formation
of the thrombus, it appears, from the experiments above referred to,
that indirectly the destruction of the red corpuscles is also of
importance.

Although largely made up of fibrin, a thrombus also contains
blood-corpuscles, both red and white, and the appearance of the mass
is modified according to the variations in the relative proportions of
these constituents.

Zahn[20] divides thrombi, according to their color, into red, white or
colorless, and mixed varieties. The red owes its color to a large
number of red blood-corpuscles, while the white and mixed forms
contain various proportions of white blood-corpuscles and fibrin and a
diminished number {58} of red corpuscles. The cause of this difference
in the color of thrombi is to be sought for in their method of origin.
When blood clots slowly in a dish, the heavier red corpuscles settle
to the bottom, and the lighter white corpuscles form a superficial
layer. Stagnant blood clotting rapidly furnishes a uniformly red mass.
The red thrombus, like the red clot, is the result of the rapid
coagulation of stagnant blood. The white thrombus, on the contrary,
largely composed of white blood-corpuscles, represents a constantly
increasing deposition of these from flowing blood. The mixed thrombi
arise from a combination of both conditions, and are usually white at
the outset. Thrombi formed in the heart and larger arteries are
usually white, those in the auricular appendages and on venous valves
are mixed, while red thrombi are more common in arteries and veins,
since the conditions favoring their origin are more frequently met in
such vessels.

[Footnote 20: _Virchow's Archiv_, 1875, lxxii. 85.]

Thrombi are frequently stratified, in consequence of the successive
deposition of new layers of blood-corpuscles and fibrin upon a
pre-existing thrombus. Circulating blood is therefore necessary for
the stratification, and such thrombi are likely to be mixed in color.
Unstratified thrombi are usually white or red, the former largely
composed of agglomerated white blood-corpuscles so moulded and
situated as to prevent a stagnation of blood in their vicinity, while
the red thrombus is rarely stratified, since its formation demands a
stoppage of the blood-current. Stratification is intimately connected
with the enlargement or growth of the thrombus, which takes place from
the surface exposed to the flowing blood, and which is greater or less
according to the seat of the thrombus.

Thrombi are usually divided into those from compression, dilatation,
traumatism, and marasmus; in all of which groups an abnormal condition
of the endothelium is to be met with.

Thrombi from compression are frequently formed in veins, in the
vicinity of growing tumors. Their presence is most constant when the
vein is compressed between a resistant surface, especially bone, and
the tumor. A compression of the smaller blood-vessels within an organ,
as the liver or kidney, may take place in consequence of chronic
interstitial inflammation, or the growth of cancerous or other
malignant tumors in such organs. The production of this form of
thrombus is sought for in the treatment of certain aneurisms by direct
pressure, the resulting stagnation of blood being followed by a
coagulation within the aneurismal sac.

Thrombi from dilatation are met with both in dilated arteries and
veins. In aneurism and varix a slowing of the blood-current is
present, and the intima of the diseased region is frequently in such
an abnormal condition that a clotting of the blood readily takes
place. The shape and situation of the dilatation are of importance in
promoting the formation of the thrombus; the more pedunculate and the
more voluminous the sac the more certain is the thrombosis.

Traumatic thrombi result from a direct injury to the vessel. This may
be mechanical, as in the application of ligatures for the obliteration
of vessels, the tearing of the veins during childbirth, and the
infliction of wounds of every variety. The injury may likewise be
chemical, from the action of caustics; somewhat analogous to which,
are the effects of heat and cold. Allied to the traumatic thrombi are
those which arise {59} from acute inflammation of the intima extending
from wounds or inflammatory processes in the vicinity of
blood-vessels.

Marantic thrombi are those whose origin is attributable to that
enfeebled condition of the body known as marasmus. This represents a
weakening of the several functions, especially the circulation,
respiration, and locomotion. Such may take place in disease or old
age; and it is important to bear in mind those diseases in which
marasmus is likely to arise, as thrombosis often proves a complication
of such affections. Protracted fevers, as typhus and typhoid,
puerperal diseases, the disturbances following surgical operations,
chronic wasting diseases, as the tuberculous and scrofulous
affections, are all likely to be accompanied by thrombosis. Stagnation
of the blood, as well as alterations of the intima, is an important
local condition in this variety of thrombosis, which is usually
valvular or parietal at the outset, and may be both arterial and
venous. Such thrombi are likely to become continued and to serve as a
frequent source of embolism.

Thrombi are also divided into primitive, or autochthonous, and
secondary varieties. The primitive thrombus is one which owes its
local origin to conditions existing at the place of its formation and
attachment. The secondary variety demands for its existence a
primitive thrombus, whose place of development is remote in time and
seat, and from which a part has been transferred to serve as the
nucleus for the secondary formation.

The continued thrombus is often confounded with the secondary variety.
Continuance is rather a quality of all thrombi, and is essentially
growth, whether by lamellation or agglomeration. Such continued
thrombi are extended in the course of the circulation, usually by a
conical end, which is pointed toward the heart in the case of venous
thrombi, but away from this organ when the thrombi are arterial.

Parietal and obstructing thrombi form another subdivision. The former
arise from a limited part of the wall of the heart or blood-vessel,
and project into its cavity. They are always in contact with flowing
blood, and are white or mixed in color and primitive. They may attain
a considerable size, and may eventually become obstructing thrombi.
The latter are so called when they are of sufficient size to cause a
considerable or total obstruction to the current of blood. In the last
case the vascular canal is wholly filled by the thrombus. The shape of
the older parietal forms is usually globular or pedunculate, owing to
the growth in all directions except at the place of attachment; the
obstructing thrombi are elongated.

Thrombi are also characterized by consistency and relative absence of
moisture. A thrombus is brittle and dry as compared with a clot. In
distinguishing between the two, difficulty arises only in the case of
a thrombus which may have formed within a few hours before death.
Post-mortem clots are moist, elastic, readily withdrawn from
blood-vessels, and have a smooth and lustrous surface. Their color is
either red, gray, grayish-yellow, or yellow, and is very often mixed.
The lighter colors are due to causes which favor the precipitation of
red blood-corpuscles before actual clotting takes place, or which
occasion an increase of the white blood-corpuscles in fibrin. The
thrombus becomes adherent to the vessel wall within a few hours, after
its formation, in the case of the red thrombus, and at once, in the
case of the white variety. A clot is never adherent, although it may
seem so from its entanglement between the trabeculae and {60} tendons
of the heart and the cavernous framework of venous sinuses. Such
apparent adhesions are easily recognized by the smooth, shining,
intact intima which is disclosed after the removal of a clot.

The thrombus not only tends to become enlarged by further depositions
of material from the blood, but it also tends to become diminished in
size from the contractile properties of its fibrinous constituent.
Moisture is forced from the thrombus in consequence of this shrinkage,
and its dryness is increased by subsequent absorption through the wall
to which it adheres.

The changes eventually taking place in the thrombus are known as
organization, calcification, and softening.

Organization is the transformation of the thrombus into a mass of
fibrous tissue. This is accomplished, according to the researches of
Baumgarten,[21] by an outgrowth of endothelium from the intima of the
vessel, the thrombus being absorbed as the growth of tissue advances.
In the case of a thrombus due to the ligation of a vessel, a
granulation-tissue also makes its way into the thrombus between the
ruptured coats, and the new-formed fibrous tissue which replaces the
thrombus becomes vascularized through this granulation-tissue. The
vascularization of thrombi surrounded by unbroken walls is most likely
to result from the extension into the thickened intima of new-formed
branches of the vasa vasorum. Cohnheim claims that the organization of
the thrombus may take place solely through the entrance of migratory
cells, without any active participation of elements of the vascular
wall. The canal is thus obstructed or obliterated by a fibrous tissue,
which is pigmented or not, as the pre-existing thrombus contained red
blood-corpuscles or not. These, when present, become transformed into
granular or crystalline haematoidin, which may remain as a permanent
constituent of the new-formed tissue.

[Footnote 21: _Die sogenannte Organisation der Thrombus_, Leipzig,
1877.]

Even when the thrombus is completely obstructing at the outset, it is
not necessary that a total obliteration of the vessel should result
from its organization. It not rarely happens, either before or after
the thrombus has yielded to the fibrous growth, in consequence of the
shrinkage of the fibrin of the thrombus or of the contraction of the
fibrous tissue replacing it, that gaps arise which become
communicating canals. Through these the blood flows, and the vessel
thus becomes only obstructed, not obliterated. The sieve-like tissue
thus formed is spoken of as the result of a cavernous or sinus-like
transformation of the thrombus. The length of time necessary for the
removal of the thrombus and its replacement by fibrous tissue varies
considerably. A vascularized granulation-tissue may be present within
a week, and in the course of a month the thrombus may have been wholly
removed, or a period of months may elapse and the thrombus and
granulation-tissue still be present side by side.

The calcification of a thrombus takes place when the latter becomes
impregnated with salts of calcium and magnesium. The condition may be
present in thrombi which are exposed to a rapidly-flowing arterial
stream, as well as in those which lie in venous pockets outside the
course of the direct current of blood. The well-known phlebolites are
examples of the latter variety. A calcified thrombus may be intimately
united to the vascular wall, the results of calcification and
organization being associated. Calcification and, in particular,
organization represent favorable {61} events in the history of
thrombosis, as through their occurrence the process comes to an end,
and disturbances, either local or remote, are prevented.

The softening of the thrombus, on the contrary, is always a source of
danger. This is partly due to the nature of the products of the
softening, whether bland or septic, and partly to the mechanical
disturbances produced by the transfer of portions of the softened
thrombus to remote parts of the body. All thrombi may become softened.
When the process of organization advances normally, the softened parts
are absorbed as rapidly as the formation of vascularized fibrous
tissue progresses. If this formation is checked or stopped, the
process of disintegration still continues. White corpuscles undergo
fatty degeneration; red corpuscles give up their coloring matter and
become converted, like the fibrin, into granules, and there results a
granular detritus. This is present as a viscid, semi-fluid material,
either red, gray, or yellow, according to the color of the thrombus.
This simple softening is to be regarded as essentially chemical in
character, and begins at the oldest portion of the thrombus and
advances toward the periphery. Its products are capable of absorption
without the production of serious disturbances, and are usually
prevented from direct entrance into the blood-vessel containing the
thrombus by the continuation of the latter from new coagulation or
deposition upon its surface. The thrombus is thus extended as the
softening progresses.

When the thrombus is comparatively free from red blood-corpuscles, the
softened product, in consequence of its yellowish color, opacity, and
viscidity, resembles pus. The so-called encysted abscesses projecting
into the cavity of the heart, from its wall, are parietal and globular
thrombi, in the interior of which softening has occurred. This form of
softening is called simple or bland, as it is free from any evidence
of local suppuration, inflammation, or general constitutional
disturbance attributable to an absorption of poisonous material.

Septic softening is accompanied by general evidences of a
blood-poisoning, and by the local phenomena of purulent inflammation.
A suppurative thrombo-phlebitis or arteritis, occurs; that is, an
acute inflammation of the wall of the vessel, corresponding in its
origin to the seat of the thrombus, and characterized by the formation
of pus. In the earliest stage the softened thrombus need not present
products differing in appearance from those occurring in simple
softening, but their effect is manifested by a rapidly-advancing
inflammation of the vascular wall and by the evidence of septicaemia.
Inoculation with such material produces a group of symptoms classified
under the head of blood-poisoning.

Cohnheim lays special stress upon the presence of micrococci in the
softened material, and it is generally agreed that the virulence of
septic softening is connected with, if not due to, the presence of
microbia. A septic softening may be induced by besmearing, with septic
material, the outside of a blood-vessel containing a thrombus, and
this form of softening is usually associated with those conditions
favoring this relation. Such are the gangrenous wounds following
surgical operations, the putrid inflammatory processes affecting the
uterine wall after childbirth, the offensive inflammations of the
middle ear, and the like. It is possible for a septic softening to
occur independently of such contiguous or continuous relations with
the surfaces of the body. It is considered, {62} however, that the
micrococci present in a softened thrombus must have obtained admission
from without through one of the surfaces of the body, mucous or
cutaneous, or through undiscovered abrasions of even intact surfaces
of peculiar structure, as the alveolar wall or the intestinal mucous
membrane. The thrombus is regarded as affording a favorable soil for
the growth and activity of the organism.

The mechanical effect of a thrombus varies according to the venous or
arterial seat of the same. Venous thrombi, as they are continued
toward the heart, tend to become completely obstructing thrombi. In
most parts of the body the venous anastomoses are so numerous that the
obstruction of a vein is readily compensated for through the
collateral venous circulation. When such a compensation is prevented
by an extension of the thrombus from branch to branch, and finally to
the trunk, an accumulation of blood in the peripheral veins must
result. The remote parts become swollen, from the distension of the
vessels with blood and the transudation of liquid, and eventually
solid material from the blood. Venous thrombosis thus leads to oedema,
and even hemorrhage. The more rapidly the obstructing thrombus
extends, the earlier and more extreme is the oedema likely to become,
while the slower the advance of the thrombus, the more favorable is
the opportunity for an enlargement of the collateral vessels through
which a sufficient flow of blood is permitted to check oedema and
preserve nutrition.

Local mechanical disturbances from arterial thrombi are scarcely
perceptible till obstruction is produced, and the results of arterial
obstruction will be mentioned in detail in connection with the
phenomena of embolism. Cardiac thrombi may occasion local disturbances
from interfering with the action of the valves of the heart. Those
thrombi which are attached to the valves, especially when calcified,
may produce inflammation and aneurism of the opposed wall of the
heart, by friction. The most frequent mechanical disturbance from the
non-obstructing parietal thrombi of the heart and arteries results
from the detachment of fragments and their transfer as emboli to
remote parts of the body.

An embolus is a foreign body in a blood-vessel, usually too large to
pass through the smallest capillaries, and the disturbances resulting
from its presence are included under the term embolism. Although most
emboli are detached portions of thrombi, any foreign body of suitable
size may become an embolus. Such are tissues, as the pulmonary elastic
fibres, fragments of diseased valves of the heart and of the intima of
arteries, or portions of tumors growing into vascular canals. Others
are globules of oil entering the torn veins when fat-tissue becomes
crushed, or air-bubbles admitted through veins either wounded by
instruments or opened after parturition by the dislodgment of their
obstructing thrombi. Still others are granules of pigment derived from
the coloring-matter of the blood, as in melanaemia, or introduced from
without, as india-ink and cinnabar. The echinococcus has been found as
an embolus, and it is highly probable that the cysticercus, the
trichina, and other animal parasites may be disseminated as emboli
over the body.

Vegetable parasites, like the bacterium and aspergillus, have also
been included in the list, although the disturbances resulting from
their presence are less due to mechanical obstruction than to
colonization and growth. The experimenter uses the most various
objects as emboli--bits {63} of wood, rubber, and glass, globules of
mercury, fragments of tissue, etc. Emboli are to be regarded as of
arterial or venous origin. The arterial emboli are carried toward the
capillaries, while venous emboli are carried toward the heart. The
effect of both is partly or wholly mechanical, and partly due to the
specific properties of the constituents.

The mechanical effect of an embolus is manifested by the obstruction
it offers to the circulation, and the degree of the obstruction
depends upon the size, shape, and density of the embolus and the
nature and size of the vessel obstructed. An embolus may be so large
as to be unable to pass through the valvular orifices of the heart. A
long and narrow embolus might pass through a vessel which would not
admit one which was short and thick. A jagged and dense embolus, by
repeated blows or prolonged and forcible contact, might cause a
weakening or rupture of the wall of a vessel, and thus produce an
aneurism. Certain vessels (the terminal arteries of Cohnheim) furnish
the sole supply of arterial blood to a district, and when they are
obstructed, the results, to be mentioned later, differ widely from
those taking place where free vascular anastomoses exist. When a trunk
bifurcates, the larger branch usually receives the embolus.

Venous emboli are those which approach the heart by the peripheral
veins of the body or the pulmonary veins, and the liver by the
radicles of the portal vein. Emboli from the veins of the body are
carried through the right side of the heart, if not so large as to be
stopped at the tricuspid or pulmonary opening. As they enter the
latter, they are carried along its course under the influence of
gravity and the direction and force of the current, which are
determined by the direction and relative size of the bifurcations of
the artery, the right primary branch being larger than the left.
Eventually, a point of the artery is reached whose diameter is less
than that of the embolus, and the latter is stopped. This point
usually corresponds with a place of bifurcation, and the embolus
frequently rides the wall separating the branches.

Emboli from the radicles of the portal vein owe their most frequent
origin to thrombi associated with inflammatory processes in the
intestine, especially of the caecum and vermiform appendage, to
inflammatory processes in the spleen and obstruction to the flow of
blood through the splenic artery, or to inflammatory changes
proceeding from the kidneys. Such venous emboli are carried toward the
heart, but are stopped on the way by the intrahepatic branches of the
portal vein.

Arterial emboli are those which enter the left side of the heart from
the lungs, which arise in the left ventricle or auricle, which may
pass through an open foramen ovale from the right auricle, or which
arise from the arterial wall. They are carried along the course of the
arterial circulation, and are distributed over the different regions
and organs of the body. Usually following the more direct course of
the circulation, they are more likely to enter the abdominal aorta
than to be carried toward the brain or upper extremities. Embolism of
the carotids, especially of the left carotid, is more likely to ensue
than embolism of the subclavians. Embolism of the coronary arteries is
rare, while embolism of the splenic artery, the left renal and left
iliac arteries, is comparatively common, and in the order mentioned.

When an embolus is found, or embolism suspected, the source is always
{64} to be searched for in those regions from which the affected part
receives its blood. The source of arterial and portal emboli is
usually found with ease, while the pulmonary embolus may come from so
wide a region, the body-veins, that much time may be spent before its
place of origin is discovered. An appreciation of the laws of the
transfer of emboli renders such a discovery almost certain.

When the embolus reaches a point beyond which it cannot pass, the
resulting disturbance depends essentially, as shown by Cohnheim, upon
the presence or absence of arterial anastomoses beyond the place of
obstruction. He gives the name terminal arteries to those which have
no anastomosing arterial branches. These are met with in the spleen,
kidneys, lungs, brain, and retina. If the obstructed artery is not
terminal, the embolus may produce no further disturbance, the
collateral supply of blood through the anastomoses sufficing for the
nutrition and function of the part. If, however, the vessel is a
terminal artery, and the embolus is completely obstructing, the supply
of arterial blood must be wholly cut off from the region beyond the
seat of obstruction.

If the embolus does not completely obstruct at once, it soon becomes
sufficiently large for this result to ensue in consequence of a
secondary coagulation. The rider assumes legs extending into the
arterial branches beyond the place of obstruction, and a body which
extends backward in the course of the circulation to the nearest
branch. The result of the total obstruction of the vessel is to cut
off the admission of arterial blood, producing a local anaemia. The
contraction of the elastic tissues of the part propels toward the
capillaries a certain quantity of the blood in the vessels beyond the
point of obstruction, till this force becomes neutralized by the
blood-pressure in the vessels surrounding the obstructed region. The
anaemic part may subsequently become engorged with blood; it may die,
a region of anaemic necrosis resulting, or the dead portion may become
softened.

The engorgement of the obstructed territory has received the name of
hemorrhagic infarction. A solid, wedge-shaped mass of a reddish-brown
color is present, whose shape is due to the arborescent branching of
the terminal arteries. According to Cohnheim, the engorgement of the
region with blood takes place from venous regurgitation into the
obstructed part, till the intravenous pressure is overcome by the
resistance of the tissues in the region affected. The capillaries and
larger vessels thus become distended, and an escape of liquid and
solid constituents of the blood takes place. If the veins are provided
with valves, or the venous regurgitant current is opposed by gravity,
the hemorrhagic infarction is prevented or greatly impeded.

Litten,[22] on the contrary, who has furnished a recent contribution
to this subject, claims that the hemorrhagic results of embolism are
not accomplished through venous regurgitation, unless increased venous
tension is produced by coughing, vomiting, and like efforts. His
experiments lead him to maintain that arterial blood from surrounding
tissues is supplied to the obstructed region through the anastomosing
capillaries. The force is not sufficient to drive the blood through
the capillaries into the veins beyond, but an accumulation takes place
in the capillaries, which become dilated and distended. The escape of
blood-corpuscles and {65} serum then takes place, the more freely, as
Weigert[23] suggests, the larger and more numerous are the
pre-existing spaces in the organ. Hence the infarction becomes the
most characteristically developed in such organs as the lungs and
spleen. Causes which obstruct the venous flow, as well as those which
increase the arterial tension, promote the hemorrhagic infarction.

[Footnote 22: _Untersuchungen uber den hemorrhagischen Infarct.,
etc._, Berlin, 1879.]

[Footnote 23: _Virchow's Archiv_, 1878, lxxii. 250.]

A necrosis of the part whose direct arterial supply is cut off takes
place when the structure of the organ affected is such that the
admission of arterial blood is wholly interfered with. This is the
case in the heart and kidneys, and to a less extent in the spleen. The
opportunity is presented for the diffusion of a fibrinogenous fluid,
lymph or blood-serum, through the cells of the organ which contains
the other essentials for coagulation, and the dead part presents the
characteristics attributed by Weigert[24] to death from clotting of
the protoplasm, coagulative or ischaemic necrosis.

[Footnote 24: _Ibid._, 1880, lxxix. 87.]

Embolism of the cerebral arteries produces softening of the brain, not
a hemorrhagic infarction or a yellowish necrosis. Weigert attributes
this result, on the one hand, to the absence in the brain of abundant
cells from which are to be had the ferment and fibrino-plastic
material necessary for coagulation, and, on the other, to the closure
of the spaces into which blood might collect by the rapid swelling of
the tissues from the exuded lymph.

The hemorrhagic results of embolism are also met with in obstruction
of branches of the mesenteric artery, which is considered by Litten,
at least from its function and in connection with its sluggish
current, to correspond with a terminal artery.

If the patient outlives these more mechanical results of embolism, the
local changes taking place are those tending to remove the
extravasated blood or the dead tissues. The embolus has become an
obstructing thrombus, and its removal is accomplished in the manner
already stated in connection with the subject of thrombosis. The
wedge-shaped nodule of hemorrhagic infarction becomes decolorized
through the absorption, in part, of the blood-pigment. That portion
which is not absorbed remains at the site of the original lesion as
granular or crystalline blood-pigment. A granulation-tissue is formed
at the periphery, which extends into the infarcted region, very much
as the endothelial and vascularized growth extends into a thrombus.
Eventually, a patch of cicatricial tissue remains as the sole
indication of the previous disturbance. This termination is rather
suggested for the hemorrhagic infarctions of the lungs. The results
are more apparent and more easily demonstrated in the case of the
anaemic necroses, and the somewhat irregular depressions with
wedge-shaped scars, seen upon the surface of the spleen or kidneys,
call attention to the probable nature of the process giving rise to
these results. A source of embolism must also be associated, that
these scars may be regarded as of embolic origin. The embolic
softenings of the brain are likewise represented in after years by
losses of substance. The superficial, yellow patches or localized
oedematous blebs, with corresponding atrophy of the convolutions
beneath, call attention to a nutritive disturbance, as do cyst-like
cavities in the deeper parts of the brain. Here, too, a source of
embolism must be found, that {66} the local destruction of tissue may
be attributed to embolic obstruction of vascular territories.

When the embolus arises from a septic thrombus, the results differ
from those above described. The embolus then carries not only
mechanical possibilities, but also a virulent action. The latter is
manifested by the rapid production of local inflammatory disturbances,
as circumscribed abscesses and gangrenous destruction of tissue. Since
emboli are frequently lodged near the surfaces of organs, a septic
pleurisy, pericarditis, or peritonitis is the usual result of the
dissemination of the virus contained in the embolus. This virus is
similar in character to that found in septic softening of the
thrombus, and, like it, is intimately connected with the presence of
microbia. Whether the latter are specific in character, as maintained
by Klebs and others, or whether they are to be included among those
associated with putrefactive processes, still remains an open
question.

The symptoms of thrombosis obviously depend upon the resulting
obstruction to the circulation of blood, and in the case of primitive
thrombi are gradual in their occurrence. The degree of mechanical
obstruction is determined by the nature of the thrombus, whether
parietal or obstructing, and by that of the vessel, whether provided
with anastomoses sufficient to permit a compensatory collateral
circulation or not. In the former case, if the thrombus is small and
deep-seated, there may be no symptoms to indicate its presence. When
the collateral circulation is insufficient to remove the blood from a
region whose efferent venous trunk is completely filled with a
thrombus, the phenomena of stagnation are produced. The part becomes
oedematous, and red blood-corpuscles escape from the distended vessel.
If the obstructed vein is superficial, the seat of the thrombus is
indicated by the resistance and sensitiveness of the part.
Characteristic disturbances of function are associated with thrombosis
of the various organs of the body. If the cerebral sinuses are
affected, mental disturbances arise; if a cardiac thrombosis is
present, it is frequently accompanied by irregularity and feebleness
of the heart. When the portal and renal veins are obstructed,
functional disturbances arise in the parts from which they receive
their blood.

The symptoms of embolism, like those of arterial thrombosis, are
primarily due to anaemia. Suddenness is their characteristic in
embolism, while they are gradual and progressive in the case of
thrombosis. An embolic anaemia is complete or incomplete according to
the terminal or anastomosing character of the obstructed vessel. The
effect of the anaemia is to stop or check the function of the part,
and varies according to the size and situation of the vessel.
Hemiplegia, or perhaps aphasia or other evidence of localized
disturbance, follows central embolism; angina pectoris, with a
disturbed cardiac action, results from embolism of the coronary
artery. Sudden suffocative symptoms, with open air-passages, suggest
embolism of the larger branches of the pulmonary artery. A
considerable haematuria often excites suspicion of an embolism of the
renal artery, the hemorrhage coming from the vessels in the
neighborhood of the obstructed region. Embolism of a large artery of
an extremity is often localized by the sensation of a blow at the
part, to be followed by absent pulsation, pallor, and coldness of the
region beyond the place of obstruction.

{67} The symptoms of the subsequent effects of thrombosis and embolism
are to be inferred from what has already been stated with regard to
the nature of the possible lesions. To enter into their detailed
consideration would demand more space than is permitted, and would
modify an established sequence or necessitate a repetition, which is
undesirable in a systematic treatise.


Effusions.

The various fluids of the body are derived from without, and admitted
into the blood-vessels. The physiological transudation through the
walls of these vessels, in the main modified serum, becomes lymph as
it appears in the several lymph-spaces. From the latter the transuded
fluid either returns through the lymph-vessels to the blood-current or
makes its appearance upon surfaces as secretions. These are variously
modified as they pass through the specific cells of glands or as they
are met with in the several closed cavities of the body.

The transudations thus occurring may vary in quantity within certain
limits, the latter being somewhat indefinite, owing to the
difficulties in the way of exactly measuring the fluid transuded. The
greater part of this transudation is represented by the quantity of
lymph flowing through the main lymph-trunk, and of the secretion from
the glandular surfaces of a given region of the body; but that
transuded fluid is not included which may return to the blood-vessels
without being carried into the general lymph-current or secreted from
a gland. Such a direct return may be considered to take place whenever
the pressure upon the outside of the vessel wall is greater than that
within the latter, or when the chemical composition of the fluids on
the two sides of the filter permits endosmosis as well as exosmosis.
This varying relation in the direction of the current through the
vessel wall is likely to be of frequent, if not constant, occurrence
in connection with the physiological processes taking place throughout
the body.

The undue accumulation of the transudation in the various closed
cavities of the body is known as dropsy, and the fluid present is
regarded as an effusion or an exudation. These terms are often applied
somewhat vaguely, now being used as synonymous, again as representing
different conditions of the transudation, which are attributed to the
varying conditions of its accumulation.

Exudation is more generally used when an inflammatory process is the
cause of the increased transudation, while effusion is more strictly
associated with causes other than inflammatory. In the present
consideration this etiological distinction will be maintained.

To appreciate the conditions under which pathological accumulations of
fluid, whether effusions or exudations, may arise, it is desirable to
bear in mind the essential conditions which prevail in the occurrence
of transudation, since the former are likewise chiefly derived from
the blood and are transuded through the walls of its vessels. These
conditions are largely dependent upon the laws governing the diffusion
of substances through an animal membrane, the vascular wall
representing the filter. As a living membrane its relation is
dependent upon vital as well as {68} physical conditions, and the
former produce certain important modifications in the physical process
of filtration.

The transudation through the vessels takes place chiefly through those
with the thinnest walls, the capillaries, although it is probable that
a certain degree of transudation may also occur through the walls of
the smallest veins. The causes which are instrumental in promoting the
circulation of the blood--viz. the contraction and dilatation of the
heart, the contraction of the arteries, the inspiratory action of the
thorax, and muscular movements throughout the body--are also essential
in producing the flow of lymph; and the existence of pressure upon the
haemic side of the filter is the first feature of importance in
occasioning the transudation. The constant removal of the transudation
from the outer side results from the pressure being less in this
position.

At the same time, an increase in the quantity of blood in the vessels
is not necessarily productive of any considerable increase in the
fluid transuded. Cohnheim calls attention to the experiments of Worm
Muller, which show that a plethoric condition may readily be produced
by the injection of quantities of blood into the circulation of
animals, the amount of which cannot exceed twice the volume of the
animal's blood without producing death. Although a temporary increase
of the blood-pressure results, a return to the normal quickly follows.
This is permitted by the propulsion of the excess of blood into the
capillaries and veins, which become consequently distended, especially
those of the abdominal organs. There is no increased transudation
corresponding with the quantity of fluid introduced, nor is there any
considerable distension of the blood-vessels of the skin, subcutaneous
or intermuscular connective tissue. Such experiments show no permanent
increase in the blood-pressure within the large veins if there is no
obstruction to the admission of venous blood into the heart,
presumably owing to their capacity for considerable distension.

Although experiments show that a simple plethora with great distension
of the capillaries of the abdominal organs occasions no considerable
increase of transudation, a different result follows a hydraemic
plethora[25] induced by the injection of immense quantities of salt
water into the blood-current--often six times as much liquid as the
animal had blood. Here, too, the arterial blood-pressure shows no
permanent increase, nor does that within the large veins become
perceptibly increased till enormous quantities of fluid are injected.
The blood flows through the vessels with increased rapidity in
consequence of the diminished friction of the diluted blood, and an
increased transudation begins at once. The various glands, salivary
and gastro-intestinal, kidneys and liver, secrete more copiously, and
the flow of a dilute lymph from the thoracic duct becomes greatly
increased, while that from the cervical lymphatics becomes moderately
accelerated. The lymph from the extremities, however, is no greater in
quantity than that flowing from an animal in a perfectly normal
condition. The localization of the increased transudation from the
blood-vessels is further characterized by the abundant accumulation of
watery fluid in all the abdominal organs and abdominal cavity, in the
salivary glands and surrounding connective tissue, while elsewhere in
the body the organs and tissues are almost invariably in the same
condition with {69} regard to moisture as are those of a healthy
animal under normal circumstances.

[Footnote 25: Cohnheim and Lichtheim, _Virchow's Archiv_, 1877, lxix.
106.]

The importance of these experiments with reference to the causes of
the transudation of fluid from the blood is obvious. The pressure upon
the walls of the blood-vessels cannot become sufficiently increased to
be accompanied with augmented transudation until limits are reached
which are beyond the possibilities of occurrence in the human body.
When such limits are attained in animals, the increased pressure,
however great it may be, does not suffice to produce a general
transudation, but one limited to the vessels of those parts of the
body whose normal function is connected with too abundant transudation
of fluid. A simple hydraemic condition of brief duration has been
proven, by experiment, insufficient to give rise to increased
transudation, neither increased secretion nor increased flow of lymph
taking place. The inference from these experiments is that an
increased transudation is more dependent upon conditions of the filter
than upon those of blood-pressure. The absence of any observable
changes in the filter leads to the assumption of an increased
permeability, of physiological occurrence in certain parts of the
body, as the chief feature in the occurrence of increased
transudations.

Dropsy arises when the transudation is accumulated. As dropsical
accumulations are transudations from the blood, essentially
blood-serum with a diminished percentage of albumen, and as such
blood-serum is practically lymph from its presence in the
lymph-vessels, dropsical effusions are to be regarded as stagnant
lymph. Such stagnations may be present in the small lymph-spaces
within the connective tissue, or in the larger lymph-sacs, as the
peritoneal, pleural, pericardial, and scrotal cavities. In like
manner, the stagnation may take place in the cavities of joints and in
those of the brain and cord, although the latter represent functional
rather than structural lymph-canals.

The term oedema is applied to the accumulation in the
connective-tissue lymph-spaces in general, while the term anasarca is
confined to those cases where the subcutaneous lymph-spaces are
concerned. The accumulation in the great lymph-cavities is known as
ascites when peritoneal, hydrothorax when pleural, hydropericardium
when pericardial, hydrocele when in the cavity of the tunica
vaginalis, hydrocephalus if within the ventricles of the brain, and
hydromyelocele when within the central canal of the spinal cord.

The accumulation of dropsical effusions may be considered as possibly
resulting from an obstruction to the channels through which the
transudation should flow, or from insufficient force to overcome
normal obstructions, or from an abnormally increased transudation.

Lymph-channels are frequently obstructed, but no appreciable diffused
retention of lymph results unless the thoracic duct is obstructed.
This rare affection is followed by enormous distension of the thoracic
and abdominal portions of the parts beyond the stenosis. Ascites and
hydrothorax may follow, but not necessarily any considerable oedema of
the peripheral parts of the body. As a result of the distension of the
thoracic duct, rupture is not unlikely to take place, and the effused
fluid contains chyle.[26]

[Footnote 26: Quincke, _Deutsches Archiv fur Klin. Med._, 1875, xvi.
121.]

{70} That the obstruction is not followed by oedema is attributable to
the innumerable anastomoses between the lymph-spaces, and also to the
probability that a part of the transuded fluid returns to the
blood-vessels when the obstruction is impassable.

The forces necessary to promote the flow of lymph have already been
mentioned, and their entire removal is inconsistent with life. A
diminution of their activity is more likely to result in a diminished
flow of lymph than its accumulation, although a slowing of the
lymph-current may represent a favoring element in the accumulation of
an increased transudation.

The occurrence of dropsy with unobstructed lymph-channels, and in the
presence of efficient agencies in promoting the flow of lymph,
indicates the importance of an increased transudation as the chief
element in the occurrence of a dropsical accumulation. An increased
transudation, with resulting oedema, is readily produced by preventing
the flow of blood from a part, and may be directly observed with the
microscope. Cohnheim states that after a sudden venous obstruction, in
case an efficient collateral circulation does not interfere, the
capillaries and small veins become distended with stagnant blood and
appear as masses of red blood-corpuscles. This distension results from
the continuance of the arterial flow into the capillaries of the
obstructed region under a pressure which is only neutralized by the
resistance of the tissues and the transudation from the capillaries.
Sotnitschewsky[27] shows that a concurrent paralysis of the vaso-motor
nerves, as claimed by Ranvier, is unnecessary. The transudation
through the capillary wall is increased, the flow of lymph from the
part is accelerated, and oedema arises when the transudation is so
much augmented that the calibre of the lymph-vessels is insufficient
for its removal; and the greater this insufficiency the greater is the
oedema. With the continuance of the arterial flow and intravenous
resistance, red blood-corpuscles are forced through the filter, and
form an important constituent of the effusion from venous stagnation.

[Footnote 27: _Virchow's Archiv_, 1879, lxxvii. 85.]

Although the existence of an increased pressure upon the capillary
wall is obvious from the experiment referred to, there is no increased
arterial pressure--rather a diminution--and the important element in
occasioning the increased permeability of the capillary wall is the
obstruction to the outflow of venous blood from the oedematous region.
In consequence of the latter the arterial flow is followed by
increased transudation.

Dropsies resulting from venous obstruction, as well as those following
an obstruction of the thoracic duct or its branches, or of the several
lymphatics of a part, are classified as mechanical dropsies. That from
venous obstruction is the most frequent, and its seat may lie in the
course of venous trunks or in the heart, lungs, or liver. The venous
obstruction must be so situated that the stagnant blood is unable to
find a ready escape through collateral branches. The more sudden and
complete it is, the more likely is the effusion to contain
considerable numbers of red blood-corpuscles.

In addition to the element of venous stagnation in producing increased
transudation, the condition of the filter is of importance. The
occurrence of oedema in chronic diseases, especially of the kidneys,
and in those attended with protracted suppuration, continued
hemorrhage, and the {71} rapid growth of tumors, has usually been
attributed to the watery condition of the blood, with a diminution of
the albumen. Cohnheim, however, suggests that the condition of the
vessel wall is of more importance than the contents as the immediate
cause of the increased transudation. The more or less protracted
action of various agents--temperature, insufficient oxygen, and
diminished albumen--is likely to so modify the condition of the
endothelium as to favor an increased permeability of the wall.
Experiments show that a simple acute hydraemia produces no increased
transudation, and that a chronic hydraemia, if connected with dropsy,
is likely to be influential by increasing the permeability of the
wall. Even in those cases where a hydraemia and an oedema co-exist,
the localization of the latter is favored by obvious disturbances of
the function of the capillary walls, as in case of the cutaneous
oedema after scarlatina. In like manner, a feeble heart, favoring
venous stagnation, and gravitation are of importance, as general
causes, in promoting dropsy in hydraemic conditions.

The possibility of the occurrence of oedema through nervous influence
is not to be denied. The localized and fleeting oedema of urticaria
and erythema, the swollen lip and tongue in connection with digestive
disturbances, are not to be explained by the two main factors of
oedema--viz. venous stagnation and increased permeability of the
vascular walls. Cohnheim refers to the rapid occurrence of oedema of
the tongue as a result of irritation of the lingual nerve, and oedema
is known to occur rapidly in cases of acute myelitis. A similar result
follows the experimental destruction of the spinal cord, although the
mechanism of its production is not apparent.

Dropsies are subdivided, as regards their distribution, into general
and local forms. The causes producing the two varieties are
essentially those already described. The causes of all local dropsies
are not always to be regarded as the same. Regions which are the seat
of mechanical dropsies are often affected by inflammation, with
abundant serous exudation--the so-called inflammatory dropsy. The
properties of the effusion and exudation are quite different, the
former having a small percentage of albumen, but few leucocytes, with
a corresponding absence of fibrin, and few or many red
blood-corpuscles. The exudation, on the contrary, is highly
albuminous, though less so than the blood-plasma; it contains numerous
leucocytes and much fibrin; under ordinary circumstances there are but
few red blood-corpuscles.

The local dropsies are often characterized by special terms. Hydrops
ex vacuo is applied to the collections of fluid found in closed
cavities with unyielding walls, as the cranium and thorax, or to the
recurrence of fluid in cavities from which the same has been rapidly
removed, in the absence of inflammatory disturbances. Collateral
oedema is usually applied to the association of oedema with
inflammatory disturbances, and represents an extension of the
inflammatory process to the region concerned. Oedema of the glottis
and circumscribed oedema of the lung are instances. The term
hypostatic oedema is often used to designate the association of oedema
and inflammation, the former caused by the latter, and to indicate the
effect of gravitation in the localization of oedema from the general
causes already mentioned.

Another localized oedema of interest, from its frequent occurrence and
{72} importance, is oedema of the lungs, often taking place toward the
end of life, at times quite suddenly. This form has usually been
attributed to increased transudation from arterial congestion or
venous stagnation. The former view is directly refuted by the
experiments of Welch,[28] who offers the explanation now accepted.
With the obliteration of three-fourths of the arterial supply to the
lungs of the animals experimented upon, no oedema resulted from the
assumed collateral fluxion into the branches of the pulmonary artery
which were left open. The obliteration of the same area of venous
distribution was necessary before the occurrence of oedema. Oedema of
the lungs was further found to result from a ligature of the aorta
near the heart. The comparative frequency of oedema of the lungs in
man, and the rarity of such extreme mechanical disturbances as those
produced experimentally, led Welch to paralyze the left ventricle. The
conditions as regards the pulmonary circulation then corresponded with
those mentioned as causes for oedema from venous obstruction. The
continued action of the right ventricle forced blood into the
pulmonary capillaries, where it was compelled to accumulate in
consequence of the inability of the left ventricle to receive and
expel it. Welch consequently regards the immediate cause of this form
of pulmonary oedema as a predominant weakness of the left ventricle. A
weak heart does not suffice for the production of the oedema, since
this condition is not found when both ventricles are alike enfeebled.

[Footnote 28: _Virchow's Archiv_, 1878, lxxii. 375.]


Degenerations.

The degenerations represent disturbances in the nutrition of the
tissues of the body, in consequence of which their functions become
impaired, if not destroyed. The latter result obviously attends the
death of cells, which may occur in the course of the degeneration. The
processes concerned are called necrobiotic by Virchow, as they
represent vital processes leading to death. Although in many of them
the cell is decaying during their continuance, its recovery is
possible with the disappearance of the conditions which have
transformed physiological into pathological processes. The
degenerations affect intercellular substance as well as cells, and are
called metamorphoses, infiltrations, or degenerations, as a
transformation of normal into abnormal material, or the addition of
extraneous substances, or the functional impairment of the part
assumes the greatest prominence.


_Cloudy Swelling, Albuminoid Infiltration, Granular Degeneration,
Parenchymatous Degeneration._

Of the various modifications in the appearance of cells under
pathological conditions, there is none, perhaps, more commonly met
with than that known by the above terms. A granular appearance may be
regarded as an essential characteristic of protoplasm, and is an
attribute of cells of epithelial origin as well as of those which
belong to other groups of tissues. The abundance of granules present
in a normal cell depends largely upon its shape, size, and situation.
These granules present various {73} relations to chemical agents, some
being soluble in alcohol and ether, others in acids and alkalies, and
many of them, especially those met with in the form of degeneration
now being considered, show from the various reactions that they are of
the nature of albumen. Since their exact composition, in all
instances, is undetermined, they are called albuminoid, and when in
excess the cell is considered to be infiltrated with these granules,
and the organ presents the appearances regarded as characteristic of
an albuminoid infiltration. A granular cell becomes much more granular
when it is thus infiltrated, and it is therefore a matter of
difficulty to recognize from the appearance of certain single cells,
as those of the liver or kidney, whether or not the number of granules
present is abnormally increased. When, however, a large number of
cells of any given organ contain more than the normal quantity of
these albuminoid granules, the appearance of the organ becomes
modified. In extreme cases the latter is swollen, doughy in
consistency, with ill-defined structural details, and in all instances
presents an opaque appearance. The term cloudy swelling is thus purely
descriptive, and was applied by Virchow to designate the optical
appearances of the condition in question. The granules, which
disappear on the addition of acids and alkalies, are apparently either
added to the cell or result from a precipitation within the same.

Frequently associated with these albuminoid granules are others,
distinctly recognizable as globules of fat. An apparent increase of
nuclei is often observed, and in certain organs, as the kidneys, the
cells seem less coherent than is normally the case. The study of this
condition in the kidneys is further of interest as indicating that the
border-line between a parenchymatous degeneration and a parenchymatous
inflammation is purely arbitrary. From similar exciting causes there
may be associated, with the described alterations of the epithelial
lining of the tubes, the exudation of albumen, the formation of casts,
the desquamation of epithelium, and the presence of leucocytes within
the tubules.

When the macroscopic changes are of moderate degree, and the
disturbance of function relatively slight, while the concurrent
alterations elsewhere, from the simultaneous action of the same cause,
are predominant and characteristic of the disease, the condition is
conveniently regarded as a degeneration occurring in the course of the
latter, rather than an inflammation. The latter term, on the contrary,
is to be applied when the granular infiltration of the cells is
associated with other evidences of an inflammatory exudation, and when
the pathological disturbances are to be directly attributed to the
parenchymatous changes.

It is customary to speak of cloudy swelling as a nutritive change, and
the condition may be induced by those causes which interfere with the
nutrition of parts or of the whole of an organ. Many authorities
regard this granular or parenchymatous degeneration as closely allied
to fatty degeneration, since many of the causes which produce the one
occasion the other. The former is often spoken of as an earlier stage
of the latter, from the frequent association of the albuminoid
granules with numerous globules of fat as a result of the more
prolonged or more intense action of a given cause.

Organs which give evidence of a granular degeneration contain, as a
rule, a diminished quantity of blood. This feature is usually
attributed to the pressure of the swollen cells upon capillary
blood-vessels. The {74} anaemic organ obviously becomes still more
cloudy, gray, and opaque in appearance from the diminished quantity or
impoverished quality of the blood.

The granular degenerations of the heart, liver, and kidneys, as a
whole, usually occur simultaneously, and afford a most important means
for the post-mortem recognition of the infective diseases. The
condition is therefore to be looked for in the exanthemata, especially
in small-pox and scarlet fever, also in erysipelas, septicaemia in its
manifold forms, diphtheria, typhoid and typhus fevers, cerebro-spinal
meningitis, etc. A common feature in all these cases is the occurrence
of fever, and it has been claimed that this element is the cause of
the degeneration. In opposition to this view is the well-known fact of
its presence in afebrile cases of poisoning from carbonic oxide, and
its absence in certain cases of pneumonia and exposure to high
temperatures.

The universal occurrence of cloudy swelling in fatal cases of the
affections above mentioned leads to the inference of its presence in
those instances terminating in recovery without obvious permanent
impairment of the organs and tissues concerned. It is therefore agreed
that the process may terminate in resolution--_i.e._ in a
disappearance of the excess of granular material. On the other hand,
its association, under circumstances, with fatty degeneration suggests
as extremely probable that the latter condition may represent a result
of the albuminoid infiltration. Even if this more serious issue
exists, the possibilities are still at hand for an absorption of the
degenerated material and a restitution of the destroyed protoplasm.
The effect upon the individual is evidently determined by the
persistence and dissemination of the condition, which, in turn, are
controlled by the immediate cause and the peculiarities of the
individual acted upon.


_Fatty Metamorphosis, Fatty Degeneration, and Fatty Infiltration._

The fat which is present within the body under physiological
conditions owes its origin primarily to the food taken. A diet which
is abundantly fatty furnishes a direct source for much of the fat
which appears accumulated in the various organs and tissues. Although
it may now appear that such a statement needs but little confirmation,
it is not long since the opinion prevailed that nearly all the fat in
the body came from the hydrocarbons of the food. This seemed all the
more plausible as the herbivora readily accumulated fat, although
their diet might contain this element in very small quantities.
Hofmann[29] made a decisive experiment with reference to the origin of
fat from fatty food by feeding a dog, made lean by starvation, with
bacon in abundance, but with little meat. In the course of a few days
the greater part of the fat introduced was deposited within the
tissues of the animal. Other experimenters have arrived at a similar
result, and it can no longer be questioned that fat, accumulated
within the body, owes its origin chiefly to the absorption of fat from
the food taken.

[Footnote 29: _Zeitschrift fur Biologie_, 1872, viii. 153.]

Another source for the fat of the body has long been
suggested--namely, the albuminates of the food. In the admirable
article on the formation of fat by Voit,[30] from which most of the
information herein {75} presented is derived, it is claimed that he
and Pettenkofer were the first to prove the origin of fat in the body,
under normal conditions, from albumen. This proof was an inference,
however, although presenting a high degree of probability. Valuable
evidence in the same direction was furnished by Kemmerich, who found
that the milk of a cow during a certain period held more fat than was
contained in the food; Subbotin and Voit have shown that more milk is
secreted the richer the diet in albumen. Still other observers have
furnished more decisive proof that fat is formed from albuminates.

[Footnote 30: _Hermann's Handbuch der Physiologie_, 1881, vi. 1, 235.]

Two sources for fat in the body under physiological conditions are
thus recognized: 1, the free fat in the food; 2, the fat derived from
the decomposition of the albuminates of the food.

Voit admits the possibility of the hydrocarbons serving as a third
source, although this possibility is unnecessary in most cases. Should
instances arise, however, where other sources for fat are found
insufficient, the hydrocarbons must be regarded as filling the gap.

Fat which is taken into the body is considered to be either consumed
or stored. That which is stored is chiefly accumulated in the great
reservoirs--viz. the subcutaneous and perinephritic fat tissue, the
mesentery, omentum, and bone-marrow--although it may be found
elsewhere, in the fluids and tissues of the body. This accumulation
serves as a source to be drawn from in case of need, and is called
upon where the easily-decomposed soluble albumen is disposed of by the
functional activity of the cells. An acting muscle demands food for
its work, and consumes first the soluble albumen, then the fat. An
excessive waste of fat is delayed by the decomposition of
hydrocarbons, but the demands may become so great that albumen, fat,
and hydrocarbons are consumed more rapidly and constantly than they
can be supplied. It being, therefore, admitted that fat is formed from
the albuminates, as well as from the fat of the food, the question
readily presents itself whether fat may not be formed from the fixed
albuminates of the body, especially from those contained within its
cells.

It is well known that in the secretion of sebum the superficial cells
of the sebaceous follicles contain fat in great quantity, while the
deeper layers are comparatively free from any appearances indicative
of the presence of fat. It is further admitted that when pus is
retained for a time the individual corpuscles contain fat-drops in
quantity and become transformed into fatty granular corpuscles.
Eventually, the pus is transformed into a detritus in which fat-drops
are found in great number.

Similar appearances may be present in the protoplasm of muscular
tissue, the cells of the liver, kidneys, and gastric glands, when
poisonous doses of phosphorus or arsenic are given. The occurrence of
an acute fatty metamorphosis of the cells of various organs in
new-born children has repeatedly been observed. The presence of fat in
various organs of the body in pernicious anaemia, and in the heart in
connection with stenosis of the coronary artery, is universally
recognized. The abuse of alcohol, long-continued obstruction to the
flow of venous blood, exposure to high temperatures, are all known to
be conditions in connection with which fat-drops are found in the
various cells of the body. The effects of poisoning with phosphorus
and arsenic are of special importance, as showing that the abundance
of fat present in the cells represents a result of the degeneration of
these cells, {76} since it takes place when the animal is deprived of
food. Although there is an evident destruction of albumen, there is
also a diminished elimination of carbonic acid and admission of
oxygen. These facts are explicable on the ground that the fat present
is not consumed, and the accumulation in the cells is evidence of this
lack of consumption. The fat is not simply stored, as none is taken
in, nor is any food received from which fat might be formed. Its
presence, therefore, must be regarded as due to degeneration.

Since fat may be formed in the body as a result of the metamorphosis
of cell-protoplasm, it is desirable to ascertain whether there are any
means by which stored fat may be distinguished from that present as
the result of a degeneration of the cell. The term fatty infiltration
has been used to indicate the presence of stored fat, the latter being
regarded as simply taken into the cell and retained for a longer or
shorter time, without any necessary interference with other functions
possessed by the cell.

In fatty degeneration, on the contrary, it is considered that the
quantity of fat present indicates a corresponding diminution in the
albuminates of the cell, and is connected with a diminution in the
function of the latter, all the greater the more abundant the fat.

It is found that in fatty infiltration, as a rule, the fat is present
in large drops, the size of the cell being increased in proportion to
the quantity of fat present. Although there may be several drops
present, they tend to run together, as is suggested by their different
size, varying proximity, and the constant presence of a considerable
quantity of protoplasm. In organs, on the contrary, whose function is
seriously, even fatally, impaired, the fat, as a rule, assumes rather
a granular form. Many minute fat-drops are present, and the cell is
not particularly, if at all, increased in size. The more abundant the
fat the less the protoplasm. Appearances are met with indicating a
transition between cells with few fat-granules and those with many.

If the morphological appearances of fatty infiltration and of fatty
degeneration were constant, there would obviously be little or no
difficulty in determining the nature of the process manifested by the
presence of fat. The exceptions occur both in fatty infiltration and
fatty degeneration. In the cells of the liver of an animal poisoned
with phosphorus fat makes its appearance in large drops, while in the
heart and kidneys of the same animal the fat is present in a granular
form.

During absorption from the intestine in the process of digestion fat
is present in the epithelium in a finely granular form. When digestion
is completed fat is no longer met with in these cells. The presence of
large or small drops, therefore, cannot be regarded as a sufficient
test of the origin of the fat. It is of equal, if not greater,
importance to bear in mind the organ concerned.

In the heart, liver, kidneys, and gastric glands, as well as
elsewhere, with the exception, perhaps, of the mammary gland, the
presence of many small fat-drops in the cells indicates a degeneration
of its protoplasm. The presence of large fat-drops, on the contrary,
in the organs and tissues, with the exception of the liver, indicates
an infiltration. Large fat-drops, then, may be present in the cells of
the liver as the result of an infiltration or of a degeneration. In
order to form a satisfactory opinion of the {77} nature of the
appearances in the liver in doubtful cases, it is important to note
the condition of those organs which may be simultaneously in a state
of fatty degeneration.

The accumulation of fat under physiological conditions is obviously
brought about, on the one hand, by those causes which permit a free
introduction, absorption, and deposition, and, on the other, by those
which check its oxidation or elimination with the secretions of the
body, as the bile, in which it may be present to a considerable
extent. A diet rich in fat, or in albuminates readily converted into
fat, offers a favorable element for the absorption of fat by the
healthy individual. If the organism demands but little of this fat for
oxidation, as in the case of the sedentary person, an accumulation is
likely to occur. This may become so considerable that obesity results.
Tissues in which normally but little fat is accumulated may become
infiltrated to a large extent. The intermuscular fibrous tissue thus
becomes loaded, and the activity, as well as the nutrition, of the
muscles is impaired. This accumulation may be manifested not only in
the voluntary muscles, but in the heart as well, which may present
abundant sub-pericardial and sub-endocardial fat, the myocardium also
being interlarded with streaks of fat, the so-called fatty
infiltration of the heart. The abdominal walls may become thickened to
the extent of a couple of inches, and the mesentery, omentum,
perinephritic tissue, and liver may become enormously increased in
weight from the mass of accumulated fat.

This infiltration of fat may take place under pathological as well as
physiological conditions. It is apparent that those causes which check
oxidation are likely also to prevent the consumption of fat, and it is
well known that the destructive processes in the lung, grouped under
the term pulmonary consumption, accomplish this result. Something
more, however, is necessary than the obliteration of pulmonary
blood-vessels and the destruction of an aerating surface. There may
be, as in emphysema of the lung, a diminished respiratory and vascular
surface, yet evidences of fatty infiltration, particularly of the
liver, are wanting. It seems probable that the constant anaemia, with
the loss of the blood-corpuscles, of pulmonary phthisis is an
important additional factor in checking oxidation in this disease.
This factor, it is needless to say, is not a necessary occurrence in
pulmonary emphysema.

Litten[31] has shown that when certain animals are exposed to high
temperatures the appearances of fatty infiltration and degeneration
are present in various organs of the body. He attributes the fatty
degeneration to a direct poisoning of the red blood-corpuscles and a
resulting diminution of the oxidizing processes.

[Footnote 31: _Virchow's Archiv_, 1877, lxx. 10.]

It is universally admitted that in chronic alcoholism a fatty liver is
frequently met with, even in the absence of those chronic interstitial
tissue-changes usually characterized under the name cirrhosis. Alcohol
is known to check the reception of oxygen and the elimination of
carbonic acid, and, whatever other disturbance of cell-activity it may
produce, its effect in favoring the accumulation of fat is directly
attributable, in part at least, to this disturbance of oxidation.

In those conditions known as cachexiae, the constant accompaniment of
progressive and wasting diseases, as cancer, leucaemia, chronic
dysentery, {78} etc., a fatty infiltration, particularly of the liver,
is a frequent accompaniment. A cachexia is dependent upon a complex
series of processes, many of which tend to check oxidation, and in
this respect is to be grouped with the conditions previously
mentioned. That the associated fatty infiltration is intimately
connected with the deficient oxidation is not to be doubted, although
the agents producing this deficiency may vary in detail.

The causes which favor fatty degeneration are numerous, and the result
represents one of the most serious conditions which can affect an
organ. As oxidation represents the chief means of normally disposing
of fat, so, pathologically, deficient oxidation favors the retention
of fat due to degeneration. Were a constant renewal of protoplasm to
take place, the degenerated fat might be displaced into the
circulation or retained within the cell. If the latter event should
occur, the result would be apparent as an infiltration, owing to the
increased size of the cell, although the condition giving rise to the
presence of the fat is a degenerative process. The importance of
impairment of nutrition as the chief cause for fatty degeneration is
thus obvious. It may readily be produced, experimentally, by measures
which check the flow of blood to a part. The same measures necessarily
prevent the presence of abundant oxygen, as fewer red blood-corpuscles
are presented.

Fatty degeneration resulting from impaired nutrition is apparent in
the heart in consequence of stenosis of its coronary arteries, in the
kidneys as a result of interstitial processes obstructing the
capillary circulation, in the brain from obliterative processes in the
arteries at the base or within the organ, and in blood-vessels from
the effect of age.

The cause of fatty degeneration may be general as well as local. In
poisoning from phosphorus and arsenic the appearances in most of the
organs indicate an actual destruction of protoplasm. Analysis of the
secretions confirms this inference, as the production of urea is
largely increased. Furthermore, there is less oxygen taken in and less
carbonic acid eliminated. As has been previously stated, these
conditions may be present in the starving animal. The fatty
degeneration is thus easily explained as a metamorphosis of
cell-protoplasm, and the deficient oxidation of the fat calls direct
attention to its accumulation rather than elimination.

In acute yellow atrophy of the liver and in cases of severe jaundice
fatty degenerations are constantly met with. That the origin and
accumulation of fat in these affections is also due to rapid
tissue-metamorphosis and checked oxidation is highly probable.
Although the elimination of urea diminishes rather than increases, as
shown by Schultzen and Riess, there are other links in the chain of
retrograde changes, as the appearance of leucin and tyrosin,
indicative of the extensive destruction of albuminates.

It is unnecessary in a work of the present character to call attention
to all the possible circumstances under which fat is present in the
body as the result of degeneration. Mention may be made of the acute
parenchymatous (fatty) degeneration of new-born children, of the
results of excessive bleeding, and of pernicious anaemia otherwise
occasioned. The fatty degeneration of the uterus after parturition, of
paralyzed muscles, and of tumors, the atrophic fatty degeneration of
the liver in chronic {79} passive congestion (nutmeg liver), are all
well-known examples. To these may be added the fatty degenerations
associated with amyloid and interstitial processes. It is apparent
that in most of these instances the common features of rapid
tissue-metamorphosis and deficient oxidation are present, and, being
present, offer a ready explanation for the appearance of the fat.

The clinical importance of fatty metamorphosis requires consideration
in connection with the description of the diseases in which its
occurrence is a constant feature. As the presence of fat in cells is
not necessarily pathological, so an interference with the function of
the cell is not invariably implied by its presence. When its existence
is suggestive of a local destruction of albuminates, a diminution of
cell-activity is a necessary consequence. Such diminished activity
must produce different results as the cells are those of muscles, of
vessels, or of glandular organs.

Even if fat is found in cells under conditions favoring such a
suggestion, it does not follow that the destruction of the cell must
result. Not only is it possible that the fat may be reserved for
eventual oxidation, and its place in the protoplasm be filled by
normal constituents, but it is also possible that the fat may be
eliminated, as such, from the body. The latter event is made apparent
by the experiments of numerous observers referred to by Cohnheim, who
have found free fat in the urine after its introduction into the
venous current.


_Cheesy Metamorphosis, Cheesy Degeneration, Caseation._

Virchow introduced the term cheesy metamorphosis, tyrosis, to
designate the process resulting in the incomplete absorption of pus
and the production of apparently similar changes in certain other
occasional constituents of the body. The characteristic cheesy
appearances were regarded as due to the inspissation of the material
concerned, in consequence of the absorption of its fluid. With this
inspissation there was frequently associated a partial fatty
degeneration, and the cheesy matter represented dead material, which
might undergo further changes, of which softening and calcification
were the more important.

Inflammatory products, as pus and fibrin, were especially prone to
become thus transformed, as well as other relatively transitory
materials of new formation--viz. tubercle and parts of various tumors.
The type of the cheesy metamorphosis was found in the enlarged
lymphatic glands, commonly called scrofulous.

The importance of a clear understanding of the cheesy metamorphosis is
now a matter of history. It is merely necessary to allude to the fact
that these cheesy products were formerly regarded as indicative of the
presence of tubercle, and were the tubercles. Tuberculization and the
cheesy condition were synonymous terms, and their indiscriminate use
led to much confusion with reference to the nature of tubercle.

Quite recently Weigert[32] has called attention to the conditions
present in necrosis resulting from the intermediate stoppage of the
blood-current in a part. The effect is manifested, under favoring
circumstances, by a cheesy appearance of the affected region, to which
the terms decolorized hemorrhagic infarction, anaemic or ischaemic
necrosis, have been applied. {80} Weigert lays stress upon the
existence of a coagulation of the protoplasm of the cells, with an
early disappearance of the nuclei, as the essential feature of this
form of necrosis, the conditions present being regarded as analogous
to those met with in the coagulation of the blood. The term
coagulative necrosis has consequently been introduced by Cohnheim to
represent the process first fully described in detail by Weigert. The
optical and physical properties of the ischaemic or coagulative
necroses of tissue are often manifested as cheesy appearances,
although the term coagulative necrosis includes conditions which do
not present a suggestion of cheese. It is thus apparent that cheesy
appearances may result in two ways: 1, by the inspissation of material
in a state of partial fatty degeneration; 2, by a coagulation of the
constituents of cells whose blood-supply is suddenly and completely
cut off. In the more restricted sense these caseous appearances are
regarded as indicative of a cheesy metamorphosis which arises by the
former of these methods. Cheesy appearances, on the contrary,
dependent upon the sudden death of a part, indicate an ischaemic or
coagulative necrosis.

[Footnote 32: _Virchow's Archiv_, 1880, lxxix. 87.]

Whatever may be the origin of the cheesy condition, the material
presenting this appearance is liable to further changes, known as
softening and calcification. The former event results from the soaking
of the dead part with liquid, in consequence of which a detritus
results. The softening usually begins at the oldest part of the cheesy
mass, and advances toward the periphery. The sanatory evacuation of
the emulsive detritus is permitted when a surface continuous with that
of the external surface of the body is reached, as instanced by the
escape of softened cheesy material from the lungs through a bronchus.
The possibility of the complete removal of the dead mass is thus at
hand, and an eventual obliteration of the resulting cavity may take
place by an adhesive inflammation of its walls.

The complete absorption of the cheesy material of an ischaemic
necrosis may occur by the extension into the latter of a
granulation-tissue from the periphery. Whenever cheesy appearances are
found on surfaces, as the degenerated tubercles of mucous membranes or
the circumscribed necroses in diphtheritic inflammation or in typhoid
fever, healing may be accomplished by their detachment as sloughs, a
clean ulcer being left. Cheesy material is frequently
encapsulated--_i.e._ imbedded in a layer of dense connective tissue, a
condition which indicates a local cessation of the process through
which the cheesy appearances arose. The same may be said of the
infiltration of the cheesy mass with earthy salts--calcification--an
event which will again be referred to in connection with the
consideration of the general subject.


_Hyaline Degeneration, Fibrinous Degeneration, Croupous
Metamorphosis._

Certain of the conditions now regarded as indicative of a coagulative
necrosis or a hyaline degeneration were previously described by Wagner
as the result of a croupous or fibrinous metamorphosis. According to
this observer, the cell-contents were transformed, under certain
circumstances, into a substance resembling externally clotted fibrin.
The formation of croupous and diphtheritic membranes, especially of
the larynx, pharynx, and trachea, was thus explained, also the hyaline
casts of the kidney.

{81} The results of this metamorphosis presented a hyaline appearance
under the microscope, and the term hyaline degeneration is now applied
more especially to indicate the production of microscopic changes,
while the hyaline appearances visible to the eye are rather included
under mucous, colloid, or amyloid metamorphoses.

The limitations in the use of the term hyaline degeneration are but
ill defined. On the one hand, there is included the transformation of
muscular tissue, first discovered by Zenker; on the other, the various
changes described by Recklinghausen and others, among which are
embraced the results of Wagner's croupous metamorphosis. As the
hyaline appearances are a frequent result of coagulative necrosis,
these terms are frequently used to indicate the same condition,
according as the optical or etiological features are uppermost in the
mind of the observer.

The hyaline or waxy degeneration of muscular fibre described by Zenker
represents a metamorphosis of the protoplasm of striated muscle in
particular, although the fusiform cells of the muscular coat of the
stomach and intestine may present a similar transformation.

The microscopic appearances are more characteristic than those visible
to the naked eye. To the latter the muscle appears paler, more
translucent, and homogeneous, and proves to be more brittle than
normal. The muscular fibres are found with the microscope to be
swollen, irregular in outline, the myosin transformed into flaky,
glistening masses, without evidence of the normal transverse
striation. These appearances have given rise to the term waxy
degeneration, which suggests a possibility of confusion with the
earlier recognized waxy degeneration of organs, due to the presence of
amyloid material. The waxy transformation of muscular fibre, however,
does not present the reaction with iodine characteristic of amyloid
substance. The degeneration of the muscle is usually regarded as the
result of a coagulation of the myosin, and it is claimed by Cohnheim
that the latter takes place only in dead muscle, either during the
life of the individual or as a post-mortem appearance.

The hyaline degeneration of muscular fibre is found in certain febrile
diseases, as typhoid and typhus fevers, scarlatina, variola, and
cerebro-spinal meningitis. It may also be met with when a muscle has
been exposed to violence, as in the insane who have been placed under
mechanical restraint. It has further been found in the vicinity of
tumors, especially where muscles have been invaded by their growth.
Cohnheim and Weil describe a similar condition in the tongue of frogs
after ligature of the lingual artery.

The pathological importance of the above-mentioned degeneration of
muscle is most prominent in cases of typhoid fever. The occurrence in
this disease of the haematoma or blood-tumor of the rectus abdominis
is thus explained, the degenerated muscle and its contained
blood-vessels being ruptured. The muscles of the thigh and the
diaphragm frequently undergo this degeneration; the change is more
rarely met with in other muscles of the body.

Recklinghausen regards a hyaline substance, hyalin, as a normal
constituent of cell-protoplasm which escapes in drops when the cell
dies. Its presence indicates a diminution in the vitality of the cell
from various causes. Under the microscope it appears as a sharply
defined, highly refractive meshwork, enclosing spaces of irregular
shape and size, in {82} which are frequently found nuclei, more rarely
cells or granules. Langhans has described this appearance as
channelled fibrin. It has been met with in the placenta, diphtheritic
membranes, blood-vessels, tubercles, and gummata.

The latest contribution to the history and nature of this form of
degeneration has been furnished by Vallat,[33] from whose article many
of the above data have been obtained.

[Footnote 33: _Virchow's Archiv_, 1882, lxxxix. 193.]


_Mucous Degeneration, Mucous Metamorphosis, Mucous Softening._

Of the various degenerations presenting a colloid--_i.e._
gelatinous--condition, the mucous variety is one of the most striking.
Its gross appearances may not differ materially from those to be
described under the head of colloid degeneration, but the diagnostic
characteristic of the change is to be found in the presence of mucin.
The presence of this substance is readily detected by the addition of
acetic acid to mucus, the effect being a fibrillated appearance of the
latter, the fibres presenting a more or less parallel distribution.
This fibrillation of mucus is regarded as the result of a coagulation
of its mucin, previously held in solution by an alkali. Mucin is thus
present in the body as a normal constituent, and, in the secretions
from mucous membranes, owes its origin to the existence of epithelial
cells, whether these represent gland-cells, as in the case of the
muciparous glands of the bronchial mucous membranes, or whether they
are superficial cells, as those of the gastric and intestinal mucous
membranes.

In the origin of mucus as a secretion from glands Heidenhain[34]
claims that a destruction of gland-cells accompanies the continuance
of the secretion. At the outset, however, the mucin escapes from the
cells, the latter remaining relatively intact. With the persistence of
the secretion there results a destruction and a new formation of the
muciparous cells. In the pathological production of mucus from mucous
membranes, as in catarrh, there is no reason to doubt that the
persistence of an irritation is the cause of abundant mucus, and that
the latter is dependent upon the rapid formation and destruction of
epithelial cells.

[Footnote 34: _Hermann's Handbuch der Physiologie_, 1880, v. 64.]

The origin of mucus from epithelial cells under physiological and
pathological conditions being apparent, it readily follows that the
epithelioid cells of tumors might be supposed to be liable to a
similar metamorphosis. It is well known that cancerous tumors,
especially those of the stomach and large intestine, are frequently
met with, which present an abundant gelatinous material, more or less
completely filling the spongy, fibrous meshwork. These are the
alveolar, gelatinous, or colloid cancers.

The gelatinous or colloid material often gives the reaction of mucin,
and the microscopic appearances of the tumor show that the jelly-like
substance lies in that part of the tumor which corresponds with the
position of the epithelioid cells. The latter are found in various
stages of degeneration, the appearances being similar to those
observed in the mucous degeneration of true epithelium.

The prevailing theory of the origin of cancer from epithelial
structures {83} readily suggests an explanation for the frequency of
the mucous variety of cancer in connection with those parts from which
mucus normally arises from the degeneration of the epithelium.

The mucous metamorphosis affects connective tissues as well as
epithelium. The Whartonian jelly of the umbilical cord and the
vitreous humor of the eye are known, through the investigations of
Virchow, to owe their gelatinous condition to the presence of mucin.
The latter lies in the intercellular substance; that is, between the
cells. The appearance of these indicates no degenerative process, but
the presence of mucin is obviously an essential constituent of the
tissue. Whether this mucin represents a transformation of the gelatin
of the intercellular substance, or a secretion from the fixed cells,
or a metamorphosis of the migratory cells of the tissue, is not known.
In mucous tissue, however, there is present mucin, wholly independent
of any epithelial degeneration. Mucous tissue is present in the eye as
a normal constituent of the adult, and in the umbilical cord as a
normal constituent of the infant at full term. It is also abundantly
met with in the subcutaneous and intermuscular tissues of the foetus.
Its pathological occurrence in the adult as a circumscribed tumor, the
myxoma, may also be mentioned.

A gelatinous substance containing mucin is found in the adult
independent of the mucous tissue, but obviously arising from a
transformation of intercellular substance. The most striking example
of this occurrence is the cystoid softening of cartilage, especially
of the costal cartilages of old people, the basis substance being
transformed into a fluid containing mucin. A similar metamorphosis is
of frequent occurrence in the intervertebral disks and in the
destruction of cartilage in acute and chronic inflammations of the
joints. The intercellular substance of cartilaginous tumors also
becomes softened and converted into a liquid containing mucin.

In osteomalacia and in the absorption of bone the mucous degeneration
of the bone-cartilage plays an important part. The lime salts are
first set free, and the cartilage then undergoes a mucous
degeneration; the product is either absorbed or remains as a liquid
within cavities of large or small size. The mucous metamorphoses of
fibrous and fat-tissues, likewise of bone-marrow, are well recognized
instances of the occurrence of a mucous transformation of the
intercellular substance of connective tissues. Finally, clotted
fibrin, so often met with as the product of the inflammation of serous
surfaces, may undergo a mucous metamorphosis, and, thus transformed,
offer a suitable material for absorption.


_Colloid Degeneration, Colloid Metamorphosis._

Laennec used the term colloid in a descriptive sense to indicate a
gelatinous appearance, and for a long time its use was thus
restricted. As the colloid appearances were found to differ in their
chemical reaction, their distribution, and their pathological
importance, and as the term was further extended to include
appearances seen with the microscope, it obviously became necessary to
subdivide the colloid series of changes according to the observed
differences. Its use is now limited to those gelatinous conditions or
appearances due to the presence of a fixed albuminate, homogeneous or
finely granular, translucent, colorless or pale {84} yellow, of
varying consistency, which does not become fibrillated on the addition
of acetic acid, and which does not change in color when acted upon by
iodine. This albuminate is considered in most instances to represent
the result of a transformation, a metamorphosis of cells, and is
associated with an impairment of their function--a degeneration which
is progressive, and leads, sometimes, to the destruction of the organ,
as occurs in certain instances of colloid degeneration of the thyroid
body. Usually, the process is limited, affecting particular parts
rather than the whole of an organ. The reaction presented by a
solution of sodium albuminate in the presence of neutral salts leads
to the view that colloid material may represent a coagulation of an
albuminous substance or substances under favoring conditions. The
presence of colloid masses in the kidney thus meets with a plausible
explanation.

The place of its typical occurrence is the thyroid body in certain
cases of goitre, and it is early met with as a homogeneous substance
replacing the granular cell-protoplasm. With its increase the latter
disappears, and the entire cell is transformed into a homogeneous
sphere. At times the colloid substance may be seen to project from the
surface of the cell as a pale rounded clump. The aggregation of these
clumps results in the presence of masses of various size, in which may
be found granules of fat or pigment and crystals of cholesterin, which
are accidental, not essential. Colloid masses are sometimes met
with--in lymphatic glands, for instance--as concretions, mulberry-like
aggregations of stratified colloid bodies, which may be infiltrated
with earthy salts. Colloid material may eventually become liquefied,
transformed into a sodium albuminate; and the presence of cysts in
certain varieties of goitre is thus explained. The coexistence in the
kidney of colloid accumulations and watery cysts has led to the view
that the latter may, under certain circumstances, result from the
former through the liquefaction of the colloid material. The same view
is held with regard to the origin of cysts frequently met with in the
choroid plexuses.

The colloid metamorphosis of cells is also to be found in the
epithelium of mucous membranes and their glands, in the prostate,
suprarenal capsule, sebaceous glands of the skin, and in the cells of
certain tumors.


_Amyloid Degeneration, Amyloid Infiltration, Waxy Degeneration,
Lardaceous Degeneration._

The colloid appearances due to the amyloid degeneration of cells are
of the greatest clinical importance from their frequent occurrence and
the gravity of the symptoms connected with their presence. In amyloid
degeneration there is the transformation of the cell-protoplasm into
an albuminous material different from other albuminates found in the
body. This transformation is at the expense of the functional activity
of the cell, and the latter becomes inert. Amyloid degeneration
represents no mere substitution, but an addition, since the affected
tissue is increased in volume. The albuminate was called amyloid by
Virchow in consequence of its color-reaction with iodine. Its method
of origin is wholly unknown, never being found in the circulating
fluids nor in articles of food. It is met with chiefly in the cell,
although its presence in the intercellular substance of old people is
recognized, and its occurrence in {85} the midst of the thrombotic
deposition on inflamed valves and in the results of inflammatory
processes is also recorded.

At present the question is under discussion whether the amyloid
degeneration may affect cells of the most varied character, or whether
it is limited to those of connective tissues. Eberth[35] maintains
that in all cases the amyloid disturbance is seated in the connective
tissue. Kyber,[36] the latest investigator, in opposition to this view
maintains that this affection is not limited to the connective tissue,
but may also be seated in the parenchymatous cells of organs. Whether
the one of these views is to exclude the other, or whether both are
not correct, remains for future investigation to decide.

[Footnote 35: _Virchow's Archiv_, 1880, lxxx. 138; 1881, lxxxiv.]

[Footnote 36: _Ibid._, 1880, lxxxi. 7, 111.]

Wherever the amyloid material may be situated, the result is a
transformation of the cells into a homogeneous, glistening, colorless
material, which occupies more space than the original cell, and, when
abundant, is accompanied with a loss of the primitive details of the
cell-structure. This material is recognized by the color it presents
when acted upon by iodine alone, by iodine and sulphuric acid, or by
methyl-aniline. The first produces a reddish-brown color, the second a
blue, and the last a violet or purple color. These reactions are all
characteristic, and the first is of special value in the macroscopic
recognition of the process, while the last two are of special
importance in the microscopic recognition of the earlier stages of the
affection.

With the advance of the degeneration and its dissemination, the organ
affected presents, in the diseased portions, pale-gray, glistening,
translucent patches, and becomes increased in size and density in
proportion to the quantity of amyloid material present. The change
appears primarily in the vessel wall or outside the same, and there
results a diminution in the calibre of the vessels, with a lessened
quantity of blood in the organ.

From the homogeneous and translucent appearance of the surface and the
increased density of the tissues the resemblance to bacon or wax is
suggested, and the terms lardaceous, bacony, or waxy degeneration have
been applied. Notable differences in degree and seat occur in
connection with the organs diseased. In the spleen, for example, the
change may be limited to the arteries of the Malpighian bodies and
their immediate surroundings. To this condition the term sago spleen
is applied, the enlarged, rounded, translucent, and projecting bodies
suggesting granules of boiled sago. The appearances of the diseased
part are further affected by the association of other conditions, as
the presence of fat or pigment. When fat is present, it is often to be
regarded as a result of the gradual and progressive increase in the
obstruction to the circulation of blood in the organ.

Although so little is known of the immediate cause of amyloid
degeneration, its distribution in the various organs of the body is
fully ascertained, as well as certain of the conditions which are
likely to be followed by its presence. It is known to occur as a
localized process in cartilage, in the conjunctiva, in certain tumors,
cardiac thrombi, scars, retained inflammatory products, and renal
casts. The causes of this localized appearance are wholly obscure, and
little or no general inconvenience results. Its presence, however, on
a large scale and in various parts of {86} the body at the same time,
is met with under such circumstances as indicate a distinct
etiological relation. An appreciation of these circumstances is of
importance, since their existence demands an investigation as to the
probable presence of the degeneration. The organs thus affected are
the spleen, liver, kidneys, and intestine. It is to their disturbance
of function that the pathological importance of amyloid degeneration
is to be especially attributed.

Other organs which may sometimes be affected are the lymphatic glands,
pancreas, suprarenal capsules, omentum, uterus, bladder, prostate
gland, heart, and thyroid body. In the case of a general diffused
infiltration these organs are variously degenerated, now some, and
again others, showing a more extensive alteration, while few or many
may be simultaneously diseased. The longer the process has continued,
the greater the degree of the disturbance and the larger the number of
the organs infiltrated. Although, in general, a period of months and
years may be demanded for these extensive changes, very serious
disturbances may arise within a short time, and Cohnheim[37] records
several cases which suggest that widely diffused amyloid degeneration
may occur within a few months--in one instance in less than four
months.

[Footnote 37: _Virchow's Archiv_, 1872, liv. 271.]

All that is at present known with regard to the etiology of this
process applies to certain general diseases with which in the course
of time it is likely to be associated. These have one element in
common, that of chronicity, and are likewise the occasion of a
progressive wasting of the body. Of these affections, that which holds
the first place is chronic pulmonary consumption, especially that form
in which extensive destruction of the lungs and ulcers of the
intestine are present. Another disease whose effects are in like
manner to be regarded as general is syphilis, and in the later stages
of this disease amyloid degeneration is likely to occur, and often to
represent by its resulting disturbances the immediate cause of death.
Again, chronic suppurative processes, especially those due to disease
of the bones and joints, are a frequent antecedent of amyloid
degeneration. Finally, the process has been found in connection with
leucaemia, chronic intermittent fever, rickets, gout, and certain
malignant tumors. This last group, however, is one in whose sequence
the degeneration is to be regarded as exceptional.

The clinical importance of this process is due to the resulting
disturbances in the function of such important organs as the liver and
intestines, the spleen and lymphatic glands, and the kidneys. The
nature of these disturbances obviously demands detailed consideration
in connection with the description of the diseases of the respective
organs. It may be mentioned here that the infiltration of the walls
leads to a narrowing of the calibre of blood-vessels, and thus a
diminution in the supply of blood to the part or organ. The resulting
impairment of nutrition becomes enhanced from the condition of the
blood, which is impoverished from the simultaneous infiltration of the
blood-making organs. The nutrition of the individual thus suffers as
well as that of the immediately diseased organ. Fatty degeneration and
atrophy of the parenchymatous cells of organs like the liver and
kidneys is the constant result of long-continued and extensive
infiltration of these glands.

Mention is intentionally omitted of the so-called amyloid bodies, {87}
corpora amylacea, considered in connection with amyloid degeneration
in most text-books on pathology and pathological anatomy. They usually
present a different reaction with iodine, their origin has but little
in common, their distribution is for the most part unlike, and little
or no clinical importance is to be attached to their presence.


_Calcification, Ossification, Petrifaction._

When salts previously held in solution are precipitated under abnormal
circumstances in the tissues of the body, the part is said to be
calcified, ossified, or petrified. Although these terms are often used
as equivalent, the last is to be regarded as more general than its
predecessors, since it includes the deposition of other than the
calcareous salts.

In the pathological ossification, as well as its physiological
prototype, the carbonates and phosphates of calcium and magnesium are
present in a specially formed tissue of the nature of bone-cartilage,
whereas calcification occurs independently of such a new-formed
tissue. The deposition of the calcareous salts takes place either in
the cells or intercellular substance of living or dead tissues, when
the terms calcification or ossification are applied, or as
accumulations of various size in tissues or canals, which are known as
concretions and calculi.

The immediate causes of the physiological deposition in the formation
of bone are so obscure that only more or less probable explanatory
theories are advanced, to all of which obvious objections arise. The
causes of a pathological precipitation may be regarded as equally
hidden. It is apparent, however, that old age usually furnishes the
necessary factors. This in part may be due to the feeble nutrition
associated with impairment of function in advancing years. In part it
may be the result of the numerous opportunities offered in a long life
for the occurrence of inflammation, the products of which are
frequently infiltrated with calcareous salts. The latter are
apparently kept in solution by the action of living cells, for, though
presented to all in the fluids of the body, they are precipitated most
constantly in dead parts or in the vicinity of those cells whose
function is presumably lessened from disease or age. The solvent
action of living cells is further demonstrated by the effect of the
giant-cells in removing calcium salts from living or dead bone.

The causes of calcification are therefore to be regarded as local,
depending upon a destruction or weakening of the cells of a
part--conditions which are directly attributable to an interference
with nutrition. The deposition of calcium salts thus represents a
disorder of nutrition, and may be experimentally produced by agencies
which occasion a necrosis of tissues.

Although the immediate causes of the precipitation of the calcium
salts must be expressed somewhat vaguely, the places and effects of
their accumulation are sufficiently well known, as are the resulting
appearances. The presence of these salts in sufficient quantity
produces a homogeneous, granular, strongly refractive appearance of
the cell or intercellular substance, in addition to a greatly
increased resistance to pressure. When muriatic acid is added to the
affected part, the salts are dissolved, with the escape of abundant
bubbles of gas when a carbonate is present, and with a rapid fading of
the glistening appearance, without effervescence, {88} when the salt
is a phosphate. After the removal, the cell or intercellular substance
is readily recognized, with such modifications in its appearance as
may be due to the action of the strong acid. The parts in which this
deposition or infiltration has taken place are either relatively
normal in appearance or variously altered from disease, and the
calcium salts are to be regarded as absorbed from the constituents of
the food and deposited, or as taken up and transferred from the bones
of the body. That both sources are drawn upon is obvious from the
abnormal presence of calcareous material in the soft parts, in
connection with increased density of the bones, as well as with a
diminution in the density of the latter. The term calcification is
more correctly applied to the presence of the salts in normal tissues
other than bone, or in the products of disease not simulating
bone-cartilage in structure. A pathological ossification is to be
considered present when an actual new formation of bone has taken
place so limited and so situated as not to suggest a tumor of bone, or
when the calcium salts are deposited in a new-formed tissue whose
structure stimulates that of bone-cartilage.

Tissues which may become calcified are, in the first instance, the
connective tissues, and of these fibrous tissue and cartilage are
especially liable. Epithelial, muscle--in particular the unstriped
variety--and ganglion-cells may also become calcified. The frequency
with which blood-vessels, especially arteries, are affected is such
that it is regarded as almost normal in advancing years that
calcareous material should be deposited within the vascular walls. A
distinction is drawn between an ossification and a calcification of
the blood-vessels. The former term should be limited to the osteoid
plates so often found as circumscribed thickenings of the aortic
intima, and which are obviously new-formed patches of fibrous tissue
in which the calcium salts are accumulated. A calcified artery, on the
contrary, is one usually of a size varying between that of the common
iliac and the temporal arteries, whose wall has become rigid and
unyielding, suggestive of a pipe-stem, from the presence of calcareous
deposits in the muscular middle coat.

From the frequency with which the osseous plates of the aorta are
associated with the fatty and fibrous changes in chronic inflammation
of the intima, the so-called atheromatous degeneration of the same, it
is customary to speak of the calcified artery at the wrist or temple
as an atheromatous artery or as evincing an atheromatous degeneration.
The common feature in the aortic changes and in the calcified muscular
coat is the element of age. They are frequently, though not
necessarily, associated. The one is the result of an inflammatory
process productive of a new, fibrous, tissue in which the calcium
salts are infiltrated; while the other is due to a deposition of the
latter in the normal, pre-existing, muscular elements of the vessel.

Calcification and ossification of blood-vessels are frequent when the
latter become dilated, as in aneurisms, whether these occur as
circumscribed tumors or as a serpentine elongation and widening of the
affected vessel.

Cartilage is also a tissue which presents a double relation to
calcareous deposition. On the one hand, there may exist an
ossification resulting from the extension of a growth of bone from the
perichondrium into the cartilage. The structure of this bone presents
all the details found in {89} normal bone--lacunae, lamellae, and
marrow-spaces. On the other hand, a section of the cartilage,
especially the costal cartilages, may contain opaque, gray, or
grayish-yellow patches, grating under the knife, which are wholly due
to the presence of calcium salts in the hyaline intercellular
substance of the cartilage. This calcification of the cartilage, which
may also involve the capsules of the cells, is frequently associated
with an ossification, although this relation is in no way essential.

Calcification of the placenta, of the fibrous framework of the lungs,
of the mucous membrane of the stomach, or of the atrophied glomeruli
of the kidney, are well-recognized instances of the infiltration of
calcareous material in normal or atrophied tissues. On the contrary,
ossification of the fibrous inflammatory products of the pleura,
pericardium, and peritoneum are instances of a pathological
bone-formation, analogous in its nature to that met with in the intima
of the aorta. The fibrinous and fibrino-cellular products of the
inflammation of serous surfaces are favorable positions for the
deposition of calcium salts, as are thrombi arising from the walls of
blood-vessels. The latter are rather instances of the calcification of
dead parts, analogous to the members of the group which includes the
formation of calculi and concretions, the calcification of the dead
foetus in abdominal parturition, of cheesy lymphatic glands, and of
cheesy material in the lungs and elsewhere. Finally, there remains the
calcification of tumors of the most varied nature, the salts being
present either in living or dead parts of the tumor.

Instances of the deposition in the tissues of other than calcareous
salts are abundantly met with in gout. In this disease cartilage,
ligaments, and tendons, bone-marrow, muscle, the endocardium and
aorta, the membranes of the brain and spinal cord, the skin and
kidneys, may contain deposits of acicular crystals and amorphous
granules. Although these deposits are largely composed of sodium
urate, calcium urate may be present with other salts, as sodium
chloride and calcareous compounds. According to Ebstein,[38] the
earthy salts in gout are deposited in necrotic patches of previously
diseased tissue. The local conditions are therefore analogous to those
concerned in the formation of chalky concretions.

[Footnote 38: _Die Natur und Behandlung der Gicht_, Wiesbaden, 1882,
45.]

Concretions and calculi are collections of earthy salts, the former
lying within tissues, the latter being present in canals opening
externally. Both represent the results of a deposition in and upon
organic material, which is often an inflammatory product, at times
surrounding a foreign body acting as the exciting cause of the
inflammation.

The earthy matter of which the concretion is composed consists mainly
of carbonate and phosphate of calcium, while the chemical properties
of the calculi often vary in accordance with the nature of the
secretion which flows by them. The salivary, pancreatic, intestinal,
lachrymal, and prostatic calculi are chiefly formed of calcareous
salts. These salts also are an important, if not the chief,
constituent of biliary and urinary calculi. In the former pigment,
bile acids, and cholesterin may also be present. Urinary calculi are
of still more varied composition, containing not only the calcium
salts, as the oxalate, phosphate, and carbonate, but also uric acid
and the urates of sodium and ammonium, in addition to the
ammoniaco-magnesian phosphate.

The infiltration with calcium salts may prove beneficial as well as
{90} injurious--beneficial under those circumstances where further
changes might prove harmful, as in the softening of cheesy material or
the maceration of a dead foetus in the abdominal cavity. The
calcification of certain tumors, as the fibro-myoma of the uterus, is
equally sanatory, the further growth of the calcified parts being thus
checked. The calcification of an aneurismal sac may prove beneficial
in strengthening a weakened blood-vessel.

The injurious effects are seen more particularly in case of the
calcareous infiltration of the middle coat of arteries. Such vessels
become converted into rigid and unyielding tubes at various parts of
their course, and the nutrition of peripheral parts becomes
correspondingly lessened. Hence, in great measure, the liability of
old people to serious inflammatory processes from trivial irritation
of peripheral portions of the body, such inflammations often
terminating in gangrene.

The calcification and ossification of the cardiac valves and the
calcification of attached thrombi, furnish frequent and constant
occasion for disturbances in the functions of the heart, resulting in
dilatation and hypertrophy, with the sequence of symptoms of chronic
valvular endocarditis.

The great clinical importance of the presence of calcium salts in the
circulatory apparatus is such that further reference in this place to
its results is unnecessary, as its special relations are more
important than its general features.

Calculi act as local causes of inflammation, and their presence is
likely to be followed by ulceration, abscess, and stenosis, perhaps
obliteration, of the smaller canals in which they may lie.


_Pigmentation._

The pathological pigmentation of the body results, presumably, from
the metamorphosis of the coloring matter of the blood or from the
introduction from without of pigments insoluble in the fluids of the
body. The former of these methods has recently been studied by
Langhans[39] and Cordua,[40] and the present views of this subject are
chiefly due to their observations, as well as to the earlier
investigations of Virchow and others.

[Footnote 39: _Virchow's Archiv_, 1870, xlix. 66.]

[Footnote 40: _Ueber Resorptionsmechanismus von Blutergussen_, Berlin,
1877.]

The haemoglobin contained in red blood-corpuscles is considered to be
composed of a coloring matter, haematin, combined with an albuminate,
globulin. When blood is removed from the body the haemoglobin is
readily separated from the corpuscles by various agents, and is then
dissolved in the plasma, which becomes lac-colored. This solubility of
the haemoglobin is of importance in connection with the absorption of
extravasated blood. During the time necessary for this process to take
place, observable changes are apparent in the color of the affected
part when its seat is superficial, especially cutaneous. These changes
in color are largely dependent upon the modifications undergone by the
haemoglobin.

It is well known that a yellowish discoloration of the general surface
frequently takes place when extensive internal hemorrhages have
occurred, constituting a form of jaundice (haematogenous) attributed
to the presence of the coloring matter of the blood. As yet there has
been no satisfactory chemical analysis of this diffused pigment, which
if not haematin must be regarded as its derivative, although a
coexistent increase of the urobilin in the urine has been observed.
The association of the stained skin and urine, {91} in the absence of
causes favoring an absorption of bile-pigment, leads to the inference
that the abnormal discoloration is due to the absorption into the
circulating fluids of the body of a pigment dissolved out of the
extravasated red blood-corpuscles. This view is confirmed by the
microscopic examination of the latter, which discloses the presence of
pale, shadowy, round outlines enclosing faintly granular material,
which are regarded as decolorized red corpuscles. In the course of a
few days glistening crystals and granules of a yellowish-red color
make their appearance in the midst of the unabsorbed blood. The
crystals are usually oblique rhombic prisms, varying in size from the
larger symmetrical shapes to the more minute, apparently granular,
forms. Acicular crystals are also to be met with, more yellow than red
in color, and are sometimes present in great abundance, although they
may be wholly absent. Virchow has applied the term haematoidin to
these crystals. Owing to the resemblance in the chemical reactions of
solutions of haematoidin and of the biliary coloring matter,
bilirubin, and to the similar crystalline forms of the latter, it has
been maintained that the two are identical. Late investigations
indicate that solutions of crystals with the appearances of
haematoidin are not invariably alike in their reaction. A solution of
these in chloroform may become decolorized when acted upon by a dilute
alkali, or it may not be thus altered. Bilirubin presents the former
relation, while chloroform solutions of the coloring matter of the
yelk of egg and of the corpus luteum, called lutein or haemolutein,
are not decolorized by an alkali. Although the crystalline forms of
haematoidin and bilirubin are not to be distinguished, it is not to be
conceded that the two substances are identical. As Maly,[41] the
latest writer on this subject, states, the term haematoidin is merely
indicative of a microscopical picture. Although the identity of the
coloring matter of the blood and of the bile is not admitted, the
intimate relation of the two is not only suggested by the similarity
of crystalline form, but by the relation determined between urobilin,
bilirubin, and haemoglobin. Urobilin is the coloring matter extracted
from the urine in fever by Jaffe, and it has since been obtained from
bilirubin by Maly,[42] who has given it the name of hydrobilirubin.
This hydrobilirubin has also been derived from haemoglobin. According
to Maly, this genetic relation between the coloring matter of the
blood and bile, shown in the production of hydrobilirubin, is the only
chemical evidence of the connection of the two pigments.

[Footnote 41: _Hermann's Handbuch der Physiologie_, 1880, vii. 155.]

[Footnote 42: _Op. cit._, 161.]

Haematoidin is to be regarded not only as directly derived from
solutions of haemoglobin, but as originating through the medium of
indifferent cells. Langhans claims that this pigment is formed within
movable cells which accumulate in great numbers in the vicinity of the
blood-clot, and, in virtue of their amoeboid properties, take into
themselves the extravasated corpuscles, entire or in fragments. The
indifferent cell may become enlarged into a giant-cell, and then
contain numbers of whole or disintegrated red corpuscles. In time
these colored corpuscles and fragments become smaller, more
glistening, and darker-colored, and eventually are transformed into
granular or crystalline haematoidin. These granules may be set free by
the fatty degeneration of the cell, or may be transferred within the
cell to distant parts.

{92} The diffusion and absorption of a solution of haemoglobin, and
the formation of crystals of haematoidin from the same or through the
medium of cells, are supplemented by an apparent inspissation and
condensation of the haemoglobin. The resulting dark-brown pigment may
remain at the seat of the hemorrhage indefinitely, and may be
accompanied with reddish-brown flakes, which, as shown by Kunkel,[43]
are composed of hydrated ferric oxide.

[Footnote 43: _Virchow's Archiv_, 1880, lxxxi. 381.]

Another feature in the absorption of extravasated blood is to be found
on examination of the nearest chain of lymphatic glands. These may be
seen swollen, of a dark-red color, and homogeneous surface. In density
and color, as well as shape, they suggest the small supplementary
spleens so frequently met with. These glands owe their change in
appearance to the presence of large numbers of unaltered red
blood-corpuscles which have entered the lymphatics traversing the
region of hemorrhage. Within the lymph-glands they undergo a
metamorphosis similar to that taking place at the part from which they
were transferred. In the course of weeks or months there remains in
the place of extravasation simply pigment, either as crystals or
granules. Such pigment may remain for years imbedded within the
tissues, or it may become absorbed, no trace of the original
disturbance remaining. Its removal may take place presumably through a
local solution of the pigment or the transfer of the granules or
crystals by means of wandering cells to the nearest lymphatic glands
or to the more remote parts of the body. An eventual elimination may
occur through the secretions, especially the urine or bile, or there
may result a deposition and permanent retention of the granules.

The investigations of Langhans are especially interesting, as
suggesting efficient means for the production of pigment by cells
whose function is intimately connected with pigmentation, as the cells
of the rete Malpighii, of the choroid, and of certain tumors. The
observations of Gussenbauer,[44] however, lead to the conclusion
earlier advanced by Virchow, that pigment may be produced by the
diffusion into cells, outside the vessels, of a solution of the
pigment of the blood in the plasma of the latter. A precipitation of
this dissolved pigment into granules is considered as eventually
taking place.

[Footnote 44: _Ibid._, 1875, lxiii. 322.]

The method of origin of pigment thus described applies only to those
discolorations which are unquestionably due to the metamorphosis of
the coloring matter of the blood. Examples are furnished not only by
the extravasation of blood on a large scale, but also by the escape of
red blood-corpuscles in small numbers. Such an escape takes place from
the pulmonary vessels in chronic obstruction to the admission of blood
into the left side of the heart. The resulting brown induration of the
lungs owes its color to the metamorphosed blood-pigment which is
present as haematoidin in the interstitial tissue of the lungs, as
well as contained within amoeboid cells in the alveolar and bronchial
cavities.

It is probable that a similar transformation of haemoglobin takes
place in the spleen and elsewhere in melanaemia. In this condition the
black granules of pigment, although differing in color and form from
haematoidin, contain iron, and have received the name melanin. These
granules are either free in the blood or are contained within the
white {93} blood-corpuscles. Their origin in the spleen is directly
suggested by their frequent presence, often in considerable numbers,
in the large, so-called splenic, corpuscles of the blood in the
hepatic capillaries. Eventually, the pigment is found at more remote
points in the circulation, and becomes fixed in the interstitial
tissue of the various organs of the body.

The black pigment of the cells of melanotic tumors, also called
melanin, is not to be directly traced to the haemoglobin. Virchow[45]
early called attention to the absence of iron in such pigment.
Ferrated and non-ferrated varieties of melanin are thus to be
recognized, the term being used in the same way as haematoidin,
indicative of a microscopical appearance. A still further complication
in the composition of melanin is suggested by Kunkel,[46] who has
isolated a ferrated pigment from melanotic tumors. It shows, however,
with the spectroscope, no relation to haematin, bilirubin, or
hydrobilirubin. That its nature is similar to the normal pigment of
the skin and choroid is suggested by the customary origin of the
melanotic tumors in such pigmented tissues, and by the resemblance in
appearance and reactions.

[Footnote 45: _Virchow's Archiv_, 1847, i. 378.]

[Footnote 46: Ziegler, _op. cit._, 100.]

That pigment of the most varied sort may be introduced into the body
from without, and may remain indefinitely in the organism, is
sufficiently well known from the results of tattooing. What is
essential in such cases is, that the pigment shall be finely divided
and insoluble in the fluids of the body. The most important of such
pigmentations are those taking place through inhalation into the
lungs. The reception by this channel of particles of soot is so common
that it is most exceptional for the lungs of an adult to be free from
the bluish-black discoloration due to this agent. Particles of
coal-dust presenting the details of vegetable structure are met with
in the lungs of individuals exposed to an atmosphere charged with this
material. The worker compelled to inhale the dust of iron eventually
accumulates a store of this substance, the quantity of which is
essentially dependent upon the length of exposure, the degree of
impregnation of the atmosphere, and the insufficient nature of the
protectives employed.

Although a large part of the pigmentation under such circumstances is
due to the direct presence of the foreign body, the appearances are
also partly the result of consequent minute hemorrhages. The coal-dust
and the iron-filings are often sharp and jagged fragments, which
penetrate the delicate tissues, and the escaping red blood-corpuscles
are acted upon by the amoeboid cells in the air-passages, with the
consequent formation of haematin or haematoidin, as are the
blood-corpuscles in larger hemorrhages. The inhaled pigment finds its
way, either directly or by the agency of amoeboid cells, into the
lymphatics and fibrous tissue of the lungs, and remains indefinitely
either in the bronchial and pulmonary lymphatic glands or in the
interstitial tissue of the lungs.

Attention may be here called to that pigmentation of the skin and
deeper-seated parts of the body, especially of the kidneys, known by
the term argyria. The long continued internal use of nitrate of
silver, in former years so extensively employed, especially in
diseases of the nervous system, results in the reduction of the silver
and its deposition as minute particles in the tissues. Whether the
silver is first reduced in the {94} intestine and then absorbed, or
whether it is absorbed as an albuminate and subsequently reduced,
still remains an open question.

Although the pathological pigmentations form an extended series of
alterations, the clinical importance of the condition may be regarded
in many instances as trivial. The pigments resulting from
extravasation produce no disturbance of function. The presence of
bile-pigment does not account for the symptoms of jaundice. The
clinical importance of melanaemia has perhaps been overrated. The
earlier observations led directly to the inference that mechanical
obstruction to the circulation in various organs might take place. The
particles of pigment and the cells containing them were so numerous
that this inference seemed quite probable. The evidence is still
lacking, however, which proves the existence of definite symptoms and
characteristic lesions as the result of the melanaemic condition.

The inhaled foreign bodies, as coal and iron, are productive of
greater disturbances, and are well known as efficient causes in the
production of chronic pulmonary consumption. The coal-miner's and
scissors-grinder's phthises usually have, as an anatomical basis,
catarrhal conditions of the aerating surfaces and interstitial
inflammations of the pulmonary connective tissue. Mechanical
obstruction to the aeration of the blood may also be present from the
extreme quantity of the foreign material in the lungs.


Tuberculosis.

Until the investigations and discoveries of the past few years, the
presence of tubercles in the various organs and tissues of the body
had been regarded as the essential element of tuberculosis. The
evidence to be presented in the following pages will show that the
immediate cause of tubercles may produce other lesions as well, and
that the presence of a specific virus as the efficient cause of
whatever may be the lesion, rather than the existence of tubercles, is
to be regarded as the characteristic feature of the disease
tuberculosis.

The tendency of the present is to regard the latter term as including
the various morbid processes connected with the origin, presence, and
growth of a specific, organized virus, their dissemination,
metamorphoses, and effects. Whether all those processes in connection
with which the virus is found are due to the latter, or whether some
may not arise and exist independently of the same, are among the
questions whose answer is remote rather than at hand.

As the presence of the cause of tuberculosis is the test demanded by
some authorities for the existence of the process, so the anatomical
classification has depended upon the existence of the tubercle. The
substitution of tubercle for organized virus in the general definition
of tuberculosis represents the distinction between the anatomical and
the etiological classification of this affection.

A tubercle was originally a small rounded body, a little tuberosity,
and at the close of the last century the specific tubercle was
distinguished from other rounded nodules.

Till the discovery of Villemin, the recognition of the tubercle was
{95} essentially based upon its anatomical characteristics. Previous
to the studies of Reinhardt and Virchow these related to appearances,
which were attributed to a deposition of material, scrofulous or
tuberculous, from the blood or lymph. The idea was eventually
maintained that this material formed the basis of a growth or new
formation, and Virchow showed that the tubercle was composed of a
tissue, of cells and intercellular substance, growing within and from
pre-existing tissues. He classified the tubercles among the tumors as
circumscribed new formations whose structure resembled that of
granulation-tissue. The specific tubercle was, at the outset, minute,
smaller than a millet-seed, submiliary, although indefinite numbers of
these minute tubercles might be grouped together and form closely
massed aggregations. From this agglomeration of single tubercles, and
their frequent association with inflammatory products, both of which
were prone to early death and transformation into a cheese-like mass,
the extensive tubercular infiltrations of organs arose. The latter
were regarded as a frequent cause of the wasting disease phthisis,
which was either pulmonary, intestinal, or renal according as the
lungs, intestine and mesenteric glands, or kidneys were the
predominant seat of the tubercular growth.

The histological features of the tubercle were further investigated by
Wagner,[47] who described the resemblances and differences of the
structure of the tubercle and the lymphatic gland. Schuppel[48] soon
after published his monograph, essentially confirming the statements
of Wagner. According to these observers, the typical tubercle, as
found in lymphatic glands, presents essentially the same peculiarities
of structure when seen elsewhere in the body. This structure consists
of a non-vascularized network of fibres, in the meshes of which cells
are imbedded. The fibrous network resembles the reticulum of a
lymphatic gland, and nuclei are often found at those points where the
fibres are united. This appearance has suggested that the network is
formed of branching and anastomosing cells. Within the meshes are
three sorts of cells--viz. giant-cells, epithelioid (endothelioid)
cells, and small, round, indifferent cells. One or several
giant-cells, each with its abundant nuclei, lie near the centre of the
tubercle or are diffused throughout the same. These are usually
immediately surrounded by the large epithelioid cells, with one or
more nuclei, which are often so numerous as to compose the greater
part of the tubercle. The indifferent cells, resembling
lymph-corpuscles, occur singly or in groups, distributed throughout
the tubercle more abundantly at the periphery, between the cells
previously described, and with them completely fill the spaces of the
fibrous network.

[Footnote 47: "Das tuberkelahnliche Lymphadenom," _Archiv der
Heilkunde_, 1870, xi. 6; xii. 1.]

[Footnote 48: _Untersuchungen uber Lymphdrusen-Tuberkulose_, 1871.]

Although the typical tubercle is thus constituted, the structural
features depend somewhat upon its age. It is generally admitted that
the freshest tubercles, as found in the external coat of the smaller
arteries of the pia mater, are composed of little else than a
circumscribed accumulation of small, round cells, without a distinct
reticulum. The giant-cells, the epithelioid cells, and the
well-characterized reticulum appear as the tubercle increases in age.
It is thought probable that the giant-cells represent the
agglomeration of the small, round cells in pre-existing cavities,
lymphatics, blood-vessels, or secretory canals. The epithelioid cells
in like {96} manner are considered to result from the enlargement or
fusion of the smaller cells, while the reticulum represents either a
secretion from, or a transformation of, the cellular elements of which
the tubercle is composed.

The subsequent history of the tubercle is dependent upon its
metamorphoses. These are known as cheesy degeneration, calcification,
and fibrous transformation.

The absence of blood-vessels, already stated, and the abundantly
cellular nature of the growth, with the possible action of
micro-organisms, result in a tendency to the early death of the cells
and a necrosis of the tubercle. This is the cheesy degeneration, and
is regarded as a form of coagulative necrosis, which begins at the
centre, advances toward the periphery, and results in the
transformation of the gray into a yellow tubercle. This termination in
cheesy degeneration likewise affects inflammatory products surrounding
the tubercle, and even relatively normal tissues in which numerous
tubercles may lie. This cheesy material either softens or becomes
infiltrated with lime salts, calcified. The softening of the tubercle
results in the formation of a material capable of removal as a
discharge from the surfaces of the body or by absorption through the
lymphatics and blood-vessels. In the former event ulcers arise upon,
and cavities communicate with, the surfaces of the body opening
externally.

The cheesy material frequently becomes calcified, thus remaining as a
comparatively inert mass. The earthy salts may be diffused throughout
a uniformly cheesy basis, or they may be deposited in a partially
softened, cheesy menstruum, when a mortar-like material results.

The tubercle becomes fibrous with the diminution in the number of its
cells and the increase in the thickness of the reticulum, with the
transformation of the latter into a homogeneous hyaline substance. The
cornified, horn-like tubercle is one whose size is diminished from the
shrinkage of its cells into glistening flakes, without an evident
associated cheesy or fatty degeneration.

The intimate relation of scrofula to tuberculosis has been variously
expressed from time to time in accordance with the amount and accuracy
of the existing knowledge. At the outset the enlargement of the
lymphatic glands, especially of the neck, characterized the scrofulous
affection. As the enlargements of the glands were found to present
intrinsic differences connected with differing clinical histories,
only those glands were regarded as scrofulous which presented the
cheesy appearances. With the recognition of the cheesy condition of
tubercles the latter were identified with the scrofulous gland, from
the cheesy condition common to both.

This identification of scrofula and tubercle prevailed till Virchow
showed that cheesy material might have a different origin, and
maintained that there were cheesy lymphatic glands without tubercle,
as well as tuberculous lymphatic glands which might become cheesy. A
distinction was thus drawn between scrofula and tuberculosis. The
former term was applied to that condition of the individual which
favored the retention and cheesy degeneration of inflammatory
products, not only in the lymphatic glands, but elsewhere in the body.
Tuberculosis, on the contrary, was characterized by the production of
tubercles which were often accompanied by retained inflammatory
products, both of which were prone to undergo cheesy degeneration.

{97} The frequent association of well-defined tubercles with what were
regarded as antecedent scrofulous disturbances also suggested an
intimacy of relation between scrofula and tuberculosis. Virchow[49]
had always maintained the possibility of regarding tuberculosis as a
heteroplastic or metastatic scrofula. The occurrence of cases of
tuberculosis without evidence of an antecedent scrofula prevented him
from making a more absolute statement of the above relation.

[Footnote 49: _Die Krankhaften Geschwulste_, 1864-65, ii. 629.]

The views with regard to the connection between scrofula and
tuberculosis have become essentially modified of late years as a
result of the investigations concerning the etiology of tuberculosis.

In 1856, Buhl[50] first published his view, although he had for
several years been impressed with the idea, that miliary tuberculosis
was an infective disease resulting from the absorption of a specific
virus. He based his theory upon the almost constant coexistence of one
or several cheesy collections and miliary tubercles. The former were
recognized as the remains of previous inflammatory processes, and the
tubercles were looked upon as the immediate result of the absorption
of this cheesy material. The individual thus infected himself.
Buhl[51] claimed that the simultaneous occurrence of tubercles and
inflammatory products was the co-effect of the same cause, and that
the acute miliary tuberculosis, as a localized process, was merely an
inflammation with the development of tubercles. He restricted the term
tuberculous inflammation, however, to those forms which necessarily
and from the beginning, produced tubercles whose presence was limited
to the tissue inflamed. The tuberculous inflammation was regarded as a
primary condition, while the acute miliary tuberculosis was a
secondary process resulting from infection.

[Footnote 50: _Lungenentzundung, Tuberkulose und Schwindsucht_, 1872,
iii.]

[Footnote 51: _Op. cit._, 123.]

The tuberculous inflammation of this author was largely characterized
by those features which, with the exception of the constant presence
of tubercles, were recognized by others as attributes of a scrofulous
inflammation. At the same time, he objected to the latter term as a
substitute, since its use would imply that no other cheesy product
than that from a tuberculous inflammation would serve as the origin of
tubercles. Buhl strictly maintained that the absorption of any cheesy
material, whatsoever its source, might give rise to a general growth
of tubercle in the body.

The views of this author were popularized mainly through the teachings
of Niemeyer[52] concerning pulmonary consumption. The latter adhered
to Virchow's views relating to scrofulous inflammation, but maintained
that most consumptives were in imminent danger of becoming tuberculous
in accordance with the doctrines of Buhl.

[Footnote 52: _Klinische Vortrage uber die Lungenschwindsucht_, 1867.]

The theory of an infectious origin of tuberculosis, advanced from time
to time by others, but most forcibly presented and maintained by Buhl,
was first demonstrated by Villemin[53] in 1865. This observer showed
that certain animals, especially rabbits and guinea-pigs, might be
successfully inoculated, beneath the skin, with fragments of gray
tubercle, cheesy products, sputum, and blood from cases of phthisis.
The development of tubercles took place within three weeks after the
{98} inoculation, and became general within four weeks. He also
demonstrated that rabbits became tuberculous when inoculated with bits
of the tumors occurring in the pearly distemper of cattle.

[Footnote 53: _Etudes sur la Tuberculose_, Paris, 1868, 528.]

Villemin's observations have been repeatedly confirmed and extended;
although subjected to the severest criticism and control, their
results are so constant that the law of the inoculability of tubercle
is almost universally regarded as fixed. Its value as a test is
evident from the statement of Cohnheim,[54] who regards as tuberculous
only that which produces tuberculosis when transferred to suitable
animals. The transfer may be made in various ways. Chauveau and others
were successful in producing an intestinal tuberculosis by the
introduction of tuberculous material into the intestinal canal of
animals, especially the Herbivora. Tappeiner[55] succeeded in
producing pulmonary tuberculosis, with or without general
tuberculosis, in dogs, by compelling them to breathe air in which were
contained minute particles of sputa from tuberculous pulmonary
cavities.

[Footnote 54: _Die Tuberkulose vom Standpunkte der Infections-Lehre_,
1880, 13.]

[Footnote 55: _Virchow's Archiv_, 1878, lxxiv. 393.]

The production of a tuberculosis of the iris, as well as of remote
organs, by the inoculation of tuberculous material into the anterior
chamber of the eye, was an ingenious method devised by Cohnheim and
Salomonsen.[56] It permitted the direct observation of the several
steps in the process of absorption of the inoculated material and
development of the tubercles.

[Footnote 56: Cohnheim's _Vorlesungen uber Allgemeine Pathologie_, 2te
Auflage, 1882, i. 707.]

The objections to the various experiments above alluded to are based
upon the assumption that the results of the inoculation are not
tubercles, but inflammatory products resembling tubercles. It is
further advocated that the inoculation of indifferent material, as
bits of glass or hairs, as well as other foreign substances, will
produce the so-called artificial tuberculosis, especially in rabbits
and guinea-pigs. It is admitted that these animals readily become
tuberculous when exposed to simple inflammatory irritants, the local
action of which frequently results in the production of cheesy
material. This termination is now regarded as due to faults in the
method of experimentation, the animals not being thoroughly protected
from the influence of the virus of tuberculosis.

The objection on the ground of structure loses its force in connection
with the well known differences in the structure of miliary tubercles
in the human body, already mentioned. The tubercles resulting from
inoculation often resemble in structure the meningeal tubercles of the
brain rather than the type presented by tubercles in lymphatic glands.
The development of tubercles in the iris may take place without any
permanent inflammatory reaction. The association of evidences of
inflammation with the development of the tubercle is therefore
unnecessary.

The experiments of Villemin have not only demonstrated the infectious
nature of tuberculosis, but have also led to a more accurate knowledge
of the relation between tuberculosis and its allied affections,
scrofula and pearly distemper.

The anatomical characteristics of scrofula have obviously proved
insufficient in determining the relation presented by this affection
to tuberculosis. The tendency to cheesy degeneration of its
inflammatory {99} products was the feature of chief importance.
Villemin showed that portions of a scrofulous (cheesy) gland when
inoculated were followed by tuberculosis, and that the inoculation of
cheesy material from non-tuberculous or non-scrofulous sources was not
followed by this result. The assumption of Buhl, that the absorption
of cheesy material, as such, was the cause of tuberculosis, was thus
disproved. The frequency with which the inoculation of cheesy
material, from what were regarded as scrofulous sources, was followed
by tuberculosis, led to more exact studies concerning the anatomical
peculiarities of scrofulous inflammation. Koster[57] called attention
to the regularity of the occurrence of miliary tubercles in the
fungous granulations of the inflamed joints of scrofulous and
tuberculous individuals. Wagner[58] and Schuppel[59] discovered that
scrofulous glands, in most if not in all instances, were tuberculous
glands. The regularity of the presence of tubercles in scrofulous
abscesses and ulcers of the skin and in scrofulous caries was shown by
Friedlander.[60] This observer likewise called attention to the
presence of agglomerated tubercles as the chief constituent of the new
formation of lupus. These anatomical discoveries resulted in uniting
more closely the affections scrofula and tuberculosis from the
histological standpoint, and the union has become more firmly cemented
from the etiological investigations.

[Footnote 57: _Virchow's Archiv_, 1869, xlviii. 95.]

[Footnote 58: _Loc. cit._]

[Footnote 59: _Op. cit._]

[Footnote 60: _Volksmann's klinische Vortrage_, 1873, lxiv.]

Schuller[61] has shown that the introduction of finely divided
material from a scrofulous joint--that is, from one containing
tubercles--into the lungs of rabbits was followed by a tuberculosis of
the tracheal wound, the lungs, and liver. Similar experiments with
reference to the introduction of lupus-tissue produced results
suggestive of tubercle, if not actually tuberculous.

[Footnote 61: _Untersuchungen uber die Enstehung und Ursachen der
Skrophulosen und Tuberkulosen Gelenkleiden_, 1880.]

The intimacy of relation between tuberculosis and pearly distemper is
a necessary result of Villemin's[62] experiment, in which the rabbit
became tuberculous after inoculation with fragments of the pearly
tumor. Gerlach,[63] and especially Schuppel,[64] showed that the
structure of the nodules of the pearly distemper is the same as that
of the tubercles of man, and that the two diseases are identical from
the histological point of view.

[Footnote 62: _Op. cit._, 537.]

[Footnote 63: _Virchow's Archiv_, 1870, li. 290.]

[Footnote 64: _Ibid._, 1872, lvi. 38.]

From the anatomical identification and the etiological connection, as
shown by Villemin, Gerlach, and Aufrecht, the pearly distemper became
designated as a bovine tuberculosis.

The experiments of Villemin were further productive in leading to the
discovery by Koch of the bacillus tuberculosis. It was early obvious
that certain cheesy material and gray tubercles possessed the
infectious qualities, and Villemin[65] maintained that the immediate
cause of the latter was a germ introduced from without, which
propagated and perpetuated itself in man and certain animals. This
view acquired prominence through the investigations of Klebs, who in
1877 claimed to have isolated the micrococci which produced tubercles
when injected into animals. Three years later Schuller[66] confirmed
the statements of Klebs, and asserted that he had been enabled to
obtain infective micrococci by cultivation from {100} miliary
tubercles, scrofulous glands and joints, and from the tissue of lupus.
Aufrecht[67] found micrococci, single and in chains, and short
glistening rods, within tubercles resulting from inoculation with
material from pearly tumors. The same organisms were found in
tubercles produced by the inoculation of tubercles from man, and he
regarded these rod-shaped bodies as the specific element productive of
miliary tuberculosis.

[Footnote 65: _Op. cit._, 620.]

[Footnote 66: _Op. cit._, 55.]

[Footnote 67: _Pathologische Mittheilungen_, 1881, p. 43.]

The isolation of the virus of tubercle was thus regarded as an open
question till the announcement by Koch[68] of the constant presence of
a hitherto unknown, characteristic, well defined organism in all
tuberculous affections, which, when isolated and introduced into
animals, produced tuberculosis, the resulting tubercles likewise
containing the organism.

[Footnote 68: _Berliner klinische Wochenschrift_, 1882, p. 15.]

The latter, the bacillus tuberculosis, was to be seen in preparations
methodically treated and carefully stained with aniline colors, by all
of which, excepting the browns, the bacillus was tinged. It was found
in miliary tubercles of the lung, cerebral and intestinal tubercle,
cheesy bronchitis and pneumonia, phthisical sputa, scrofulous glands,
and fungous inflammation of the joints. It was also seen in the
nodules of pearly distemper and in the cheesy masses from the lungs of
cattle. It was furthermore met with in the cheesy lymphatic glands of
swine, in the tubercular nodules of a fowl, and in the tubercles of
guinea-pigs, rabbits, and monkeys. The bacilli were likewise found in
the tubercles resulting from the inoculation of animals with
tubercular virus from its various sources.

The microphytes were described as very slender rods, varying in length
from one-fourth the diameter of a red blood-corpuscle to its entire
diameter, and spores were occasionally seen within the rods. In shape
and size they resembled the bacilli of leprosy, but the latter were
narrower and pointed at the ends. They were found in greatest
abundance when the tuberculous process was recent and rapidly
advancing, and were present within, as well as between, cells. The
younger giant-cells contained them in larger numbers than the older
forms. They were present at the periphery of cheesy nodules rather
than at the centre.

The bacilli were cultivated through successive generations and
required a temperature of between 30 degrees C. and 41 degrees C. (86
degrees F.-105.8 degrees F.) for their development, one of 37 degrees
C. or 38 degrees C. (98.6 degrees F. or 100.4 degrees F.) being the
most favorable. The crop first became apparent on the tenth day after
sowing, and the growth extended through a period of three to four
weeks, forming a compact scale. The cultivated bacilli, even
propagated through several generations, when inoculated, produced the
same positive results as follow the inoculation of fragments of
tuberculous material, although animals might be used which are not
easily infected with tuberculosis.

Koch's publication was immediately followed by a statement from
Baumgarten[69] of his discovery of rod-like bacteria in the tubercles
of rabbits resulting from the inoculation with pearly masses, and in
the pleural and pericardial tubercles of man. They were made evident
by treating the sections for microscopic examination with very dilute
solutions of soda or potash.

[Footnote 69: _Centralblatt fur die med. Wissenschaften_, 1882, xv.
257.]

{101} The discoveries of Koch thus show that the production of
tuberculosis is dependent upon the presence of distinctive bacilli,
and that these bacilli are present not only in miliary tubercles, but
in scrofulous glands and joints, in cheesy inflammation of the lungs,
and in the pearly distemper of animals. The identification of
tuberculosis with the pearly distemper and certain scrofulous
affections is thus established from the etiological as well as the
histological point of view.

As the bacilli are to be regarded as the virus of tuberculosis, so
their introduction into the human body is necessary for the production
of this disease in man. It is obvious, however, that other factors
than the virus are necessary, for not every one exposed to the
reception of tubercular bacilli becomes tuberculous. It may well be
that scrofula is still to be regarded as that condition of the solids
and liquids of the body which offers favorable opportunities for the
retention and growth of the bacilli, and thus for the production of
tuberculosis. Formad[70] claims that he has discovered structural
peculiarities of tissue as a cause for the scrofulous habit, which he
regards as synonymous with a predisposition to tuberculosis. These
peculiarities are manifested by a narrowness of the lymph-spaces and
their partial obliteration by cellular elements. He also maintains
that these features are not only of congenital origin, but may be
acquired through malnutrition and confinement.

[Footnote 70: _Studies from the Pathological Lab. of the Univ. of
Penna._, reprint, 1882, xi. 3.]

The occurrence of a local, circumscribed tuberculosis in extreme old
age, without antecedent or other concurrent evidence of scrofulous
disturbances, suggests that favorable opportunities for the
development of the tubercular bacillus may arise in advancing years.
In like manner, the frequent termination in phthisis of cases of
diabetes suggests the likelihood of tuberculous inflammation arising
in the absence of any evidence of previous scrofulous or tuberculous
disease. The scrofulous condition or constitution, as indicated by
vulnerable tissues, with a protracted course of inflammations, and a
persistence of their products, with a tendency to cheesy degeneration,
may still exist without a sign of tuberculosis. Those who claim that
scrofula and tuberculosis are identical must, in the light of Koch's
discovery, demonstrate the presence of the bacillus in all scrofulous
inflammations, and deny the existence of scrofula apart from
indisputable manifestations of the activity of the bacilli of
tuberculosis. It may be that such evidence will be presented; until it
is collected scrofula and tuberculosis are to be regarded as distinct
though often coexistent. The scrofulous person is frequently
tuberculous, the tuberculous person is usually scrofulous; the
non-scrofulous person, however, may die of tuberculosis, while the
individual may be scrofulous without containing tubercle.

The actual inheritance of tuberculosis is very unlikely, although this
disease is frequently found in successive generations of a single
family. The various members of the family are rather to be regarded as
furnishing a suitable soil for the growth of the tubercular bacillus,
and their exposure to its seed is favored by the existence of
tuberculosis in one or more members of the household. The scrofulous
condition is still to be regarded as hereditary as well as acquired,
and the scrofulous remain as the class to be especially protected from
the reception and effects of the bacilli of tuberculosis.

{102} It is obviously a matter of importance to determine in any given
case of phthisis whether bacilli are present or absent. A ready means
of ascertaining this fact is offered by the examination of the sputum
in cases of pulmonary phthisis, the feces in intestinal phthisis, the
urine in renal phthisis, and the aspirated pus in cases of supposed
tuberculosis of the joints. Koch has found in examining the sputa from
numerous cases of phthisis that the bacilli were present in one-half
the number, and that they were absent from the sputa of individuals
who were not phthisical. Balmer and Fraentzel[71] have found bacilli
in the sputum from one hundred and twenty cases of phthisis, and
concluded that the progress of a case of pulmonary tuberculosis might
be readily determined from the number and degree of development of the
typical bacilli present in the sputum. The more numerous and
well-developed bacilli, with distinct and constant spores, were found
in the graver cases, which advanced more rapidly. The sputum of the
protracted cases contained few, small, and thin bacilli with scanty
spores. The presence of fever was associated with numerous bacilli,
while its absence was noted in those cases where but few were present.

[Footnote 71: _Berliner klinische Wochenschrift_, 1882, xlv. 679.]

The bacilli are readily detected by means of the staining method
devised by Koch. Various modifications have been presented from time
to time, of which that of Ehrlich[72] has proved the most
satisfactory. The essential features are to obtain a dry, thin layer
of a selected portion of the suspected sputum, which is then to be
deeply stained with fuchsin or methyl-violet; the excess of color is
to be removed with nitric acid, and the preparation is then ready for
examination with the microscope. A power of four or five hundred
diameters is sufficient for the recognition, and the object should be
illuminated with a flood of light through a large diaphragm or an
achromatic condenser. The bacillus retains the color notwithstanding
its exposure to the acid, and the violet colors are more strongly
presented if the preparation is tinted yellow after the action of the
acid. If the bacilli are stained red with fuchsin, the background
should be made blue. It is important that the reagents should be
freshly prepared and filtered, that other bacteria may not obscure the
picture, and that all the apparatus employed should be thoroughly
clean.

[Footnote 72: _Allg. med. Centr. Zeitung_, 1882, xxxvii. 458.]

A fragment of thick, opaque sputum is to be taken in forceps, placed
on a cover-glass, and spread into a thin layer by means of a second
cover-glass. The prepared slide is then to be passed slowly through an
alcoholic flame, or that of a Bunsen burner, till the layer of sputum
is dried. A saturated alcoholic solution of methyl-violet or fuchsin
is made and filtered, and added, drop by drop, to a filtered,
saturated solution of aniline oil shaken in water. The color is to be
added with stirring till an opalescent film forms on the surface of
the mixture. The slide containing the dried sputum is to be placed in
or on this staining fluid, and allowed to remain for half an hour or
less, the application of warmth hastening the process, when it is
removed, and the specimen is decolorized in a solution of one part of
nitric acid and two parts of water. The preparation is then washed in
water, and may be examined directly in water, glycerin, or, after
dehydration in alcohol, in oil of cloves. The tinted bacilli are made
more prominent by a secondary staining, for a minute or two, of the
red (fuchsin) preparation {103} in a concentrated solution of
methyl-blue, the violet preparation being secondarily stained in a
like solution of aniline-brown. If the preparation is to be
permanently preserved, it should be dehydrated in strong alcohol after
washing with water, and it may then be treated with oil of cloves and
mounted in Canada balsam.

After the observer has become thoroughly familiar with the tubercle
bacilli by means of the method of Ehrlich, much time may be saved by
following that of Baumgarten.[73] The cover-glass bearing the dried
sputum is placed in a very dilute solution of caustic potash (two
drops of a 33 per cent. solution in a watch-glass of distilled water)
till the layer of sputum becomes transparent. The cover is then placed
on a slide moistened with a drop of water, tapped slightly, and
examined with the microscope. The bacilli are readily seen, and may be
differentiated from other varieties of bacteria, if necessary, by
again drying the object and examining it in a drop of a dilute watery
solution of aniline-violet or of other preparations of aniline used
for staining nuclei. The tubercle bacilli remain unstained, while
putrefactive bacteria are tinted.

[Footnote 73: _Centralblatt fur die med. Wissenschaften_, 1882, xxv.
433.]

The tubercular products of the invasion of the body by the bacillus
tuberculosis are regarded as primary or secondary, according as they
are present at that part of the body which directly receives the
organisms or as they are dependent upon the transfer of the latter to
parts remote from the region of their admission and immediate effects.
This differing relation is also expressed by the terms local and
general tuberculosis. In the former the bacilli excite the growth of
tubercle only at a given part of the body. Their apparent effects may
be wholly limited to this region, and it not rarely happens that the
same is quite distant from the channels through which the bacilli are
admitted. A general tuberculosis occurs when the latter are
disseminated over the body, and their effects, especially the
production of numerous tubercles, are found at various parts. The
dissemination may take place at the time of entrance, or, as is more
commonly the case, apparently occurs at some subsequent period, the
immediate disturbances being localized at a given portion of the body.
The necessary conditions being here offered for the propagation of the
bacilli, their sudden distribution in great numbers is afterward
permitted when favorable opportunities arise for their absorption.
Such conditions are present when the local tubercular growths extend
into lymphatics or blood-vessels. The frequency with which scrofulous
glands are tuberculous--that is, contain miliary tubercles--is already
fully recognized, and a tuberculosis of the lymphatic glands is
essentially regional. These glands become affected in consequence of
disturbances, the local effects of which may have wholly disappeared,
in the region from which they receive their lymph. The cervical glands
become permanently enlarged, perhaps tuberculous, in connection with
persistent or recurrent inflammatory processes in the tonsils and
pharynx, the bronchial glands from similar bronchial or pulmonary
affections, and the mesenteric glands from like intestinal
disturbances. In such instances, the direct reception of the bacilli
into the lymph-current is assumed rather than demonstrated from a
knowledge of the possibilities of absorption and an appreciation of
the conditions in the glands.

That an actual growth of tubercles from the wall of the intestinal
{104} lymphatics may take place has long been known, and Ponfick has
recently discovered that tubercles may be found growing from the wall
of the thoracic duct. The possibility of the direct admission into the
lymph-current of the infective element in tuberculosis is thus
apparent, and its indirect entrance into the blood-current is equally
obvious. That the bacillus of tubercle may be directly received into
the blood-current is likewise evident from the observations of
Weigert, who found tubercles growing from the walls of the pulmonary
blood-vessels, venous as well as arterial. This discovery of a
tuberculosis of the blood-vessels was confirmed by Klebs, who had
found a tuberculosis of the azygos veins. The occurrence of multiple
miliary tubercles of the pulmonary veins, especially near the place of
entrance of smaller branches, has been asserted by Mugge,[74] although
appearances similar to those described by him may be met with, due
simply to the agglomeration of white blood-corpuscles and their
necrosis. Such a condition simulates very closely the miliary
tubercle, but is usually analogous to the appearances figured by
Virchow,[75] and described by him as one of the phenomena of
coagulation. In his observation the white bodies were adherent to the
red clots, and were with them drawn from the pulmonary artery.

[Footnote 74: _Virchow's Archiv_, 1879, lxxvi. 243.]

[Footnote 75: _Die Cellular Pathologie_, 4te Auflage, 1871, 184.]

With the admission into the body, and the colonization of the
tubercular bacilli, their effects may either be progressive until the
death of the individual is occasioned, or, with the cessation of the
growth of the bacilli or a possible modification of their noxious
properties, recovery may ensue. The history of scrofulous glands, as
well as that of circumscribed pulmonary inflammation in scrofulous
persons, both presumably of a tuberculous nature, show that the
effects of an invasion of the parasites may be overcome.

The regions of the body which are usually the seat of a primary
tuberculosis are unquestionably the respiratory and intestinal tracts.
With regard to the first of these regions, the one most frequently
affected, there can be no doubt that in most instances the inhaled air
carries the bacilli or their spores, or both. Their constant presence
in the sputum of the frequent cases of tuberculous phthisis suggests a
ready means for their escape into the atmosphere. The well recognized
infective qualities of the sputum, as demonstrated by the various
experiments before the bacillus was discovered, demand the thorough
disinfection of phthisical sputa, since these are in all probability
the chief source of the dissemination of the disease.

The tuberculosis of the intestine in like manner is to be regarded in
the main as the result of an absorption from its surface of the
specific agent. An obvious direct means of the approach of the bacilli
is offered in the sputum, which, when swallowed, is likely to retain
its virulent properties. The frequent coexistence of chronic pulmonary
and intestinal tuberculosis is thus most readily explained. To what
extent the presence of the bacilli in the pearly distemper of cattle
and in the tuberculosis of other edible domesticated animals, as fowls
and swine, may lead to an infection of the intestinal wall, still
remains an unsolved problem. It is not yet determined at what
temperatures the bacilli are destroyed, although their growth takes
place only between 30 degrees C. (86 degrees F.) and {105} 41 degrees
C. (105.8 degrees F.). The inoculation of pearly masses produces
tuberculosis in certain animals, yet the effect of cooking in
destroying the bacilli and their spores is likely to prove of great
importance. Aufrecht's[76] attempts at inoculating rabbits with cooked
pearly masses proved unsuccessful. Schottelius[77] publishes an
interesting series of observations relating to the prolonged use of
meat from cattle affected with the pearly distemper, and shows that
after a period of years no disease of the nature of tuberculosis
occurred among the one hundred and thirty individuals included in the
families concerned. Whatever may be the value of this negative
testimony, there is, as yet, no evidence on the other side which
satisfactorily determines the point in question--viz. that the flesh
of animals affected with pearly distemper produces tuberculosis in the
human consumer.

[Footnote 76: _Op. cit._, 51.]

[Footnote 77: _Virchow's Archiv_, 1883, xci. 129.]

The milk from cows thus diseased has likewise been regarded with
suspicion, and the frequency of intestinal tuberculosis among children
has been attributed to this source. Although the theoretical
possibility of the escape of the bacilli into the milk of cows
affected with pearly distemper is obvious, their presence in such milk
is first to be demonstrated under conditions which necessitate their
origin from the animal. If boiling the infective material for three
minutes destroys its virulence, as claimed by Aufrecht, a ready means
is offered of destroying the tubercle bacilli which may be present,
not only in the milk from animals affected with pearly distemper, but
in all milk which has been exposed for a certain time to an atmosphere
which may contain the bacilli of tuberculosis. In the light of our
present knowledge extreme hygienic precautions are only demanded in
those cases where such a congenital or acquired basis (constitution)
is present as facilitates the development of tuberculosis.


Morbid Growths.

In a system of practical medicine it is obviously important to include
under the head of Morbid Growths not only what is spoken of by the
surgeon as a tumor, but also those new formations of tissue which, in
virtue of their nature, seat, manner of growth, and retrograde
changes, produce an important series of disturbances in the
physiological processes of the individual. The surgeon deals
essentially with the swelling, which, producing irregularities in the
outline of the accessible surfaces of the body, is regarded as an
excrescence or outgrowth. It is important for him to realize the
nature of this swelling, that he may follow a different treatment for
the abscess, the wen, the watery accumulation, or the fleshy mass. The
last is the tumor in the limited sense; it is the growth which, though
called morbid, becomes so only in consequence of its presence being
associated with symptoms whose existence and persistence interfere
with the well-being of the possessor.

The physician, on the contrary, is more concerned with the tumor as a
growth than as a swelling. The latter element in deeply-seated
portions of the body may not be brought to his attention. The growth
takes place in such a manner as to be productive of certain symptoms
more or less serious, among which swelling is least obvious. The
morbid {106} growth to him becomes prominent as it displaces or
replaces normal tissues by those newly formed, which may or may not be
normal to the part in which the growth is situated. His tumor is
therefore a morbid growth, a new formation, a neoplasm or pseudoplasm,
rather than a swelling, a bunch, or an excrescence.

In a consideration of the general pathology of morbid growths the
first question which suggests itself relates to the method of origin
of the tumor. The tendency of the present seeks for a local cause, and
the most recent theory, that of Cohnheim, demands an accumulation of
dormant embryonal cells as such a cause. Cohnheim supports this view
by the experiments of Zahn and Leopold, which show that foetal
cartilage transplanted into the tissues of a mature animal may grow so
rapidly as to present the characteristics of a cartilaginous tumor,
while tissues transferred from the animal after birth do not increase
in size, but are usually absorbed.

As the active elements of the growth are cells, and all cells
admissibly arise from pre-existing cells, it follows that the
primitive cells of a tumor are derived from those resulting from the
segmentation of the ovum or are introduced from without. Numerous
experiments have been made with a view to the inoculation of tumors,
the transplantation of living fragments of the latter to the living
tissues of a healthy individual, for the sake of producing a tumor,
but hitherto almost invariably without success. The alternative
remains that the embryonal cells are those whose derivatives are
present in, and form the essential element of, the morbid growth. All
tumors may thus be said to have an embryonal origin. As the
segmentation of the ovum eventually results in the production of
normal tissues and groups of tissues whose structure and function are
wholly different, so the possibility of the production of abnormal
groupings of tissue with corresponding irregular manifestations of
function is obvious.

The cells of the part from which a tumor arises may be regarded as
indifferent, those whose limitations of growth, like the early
embryonal cells, are only determined by the changes they undergo, or
their limits of growth may be already defined in kind, and their like
be produced in the formation of the tumor. The origin of a tumor thus
presupposes the existence of such indifferent cells, or the presence
of those whose limit of transformation has already been reached. The
leucocytes of the body, whether found as white blood-corpuscles or
lymph-corpuscles, or as the wandering cells of connective tissue, are,
as Virchow has indicated, such indifferent cells. Always present and
apparently transitory, what they are to become can only be determined
from their condition and surroundings at the time of observation.
Although their actual transformation into the various cells of a more
permanent type is merely a matter of inference in the growth of
tumors, the evidence presented by Ziegler[78] leads directly to the
conclusion that their presence is necessary to the new formation of
tissues whose growth is the result of an inflammatory process. These
tissues may occur under such restrictions as permit them to be
classified as tumors, and the granulomata, or tumors whose tissue
resembles that of the granulations upon the surface of a wound,
represent a well defined group in structure as well as method of
origin.

[Footnote 78: _Op. cit._, 150.]

{107} The production of the cells of a tumor from indifferent cells is
at present an assumption, based upon the frequent presence of the
latter within tumors and in their vicinity; and the obvious objection
arises that even if the presence of these cells is admitted as
indispensable, it by no means follows that they are directly
transformed into the more characteristic cells of the tumor. That they
may serve for the nourishment of the amoeboid cells of certain tumors
is suggested by the existence of both in morbid growths, and the
well-known property of amoeboid corpuscles to take in formed material,
even cells, from without.

The origin of tumors from cells whose limits of growth are already
defined is rendered probable from the absence, entire or in great
part, of indifferent cells from certain tumors, and the direct
continuity of the latter with a similar normal tissue of the body.
Various tumors show such an intimate relation, and there is no sharply
defined border-line between the normal tissue and that which
represents the tumor. The occasional presence of islets of well
characterized tissue at points more or less remote from the normal
position of such tissue at the time of their discovery suggests a
feasible source for an eventual tumor. Virchow long ago called
attention to isolated nodules of cartilage within bones in the
vicinity of epiphyseal cartilages, probably detached from the latter,
which might serve as the origin of a cartilaginous tumor in this
region. This inclusion of tissue is also suggested by the frequency of
certain tumors in certain regions where the developmental conditions
are favorable. Lucke[79] mentions the frequency of dermoid cysts near
the median line of the head, the vicinity of the eye, and the side of
the neck. Such regions are those where fissures exist during foetal
life, with normal involutions of the outer germinal layer; which
involutions may become irregular, and eventually included or shut in,
as the fissures become closed. A similar explanation is offered for
the frequent occurrence of cartilaginous tumors at the angle of the
jaw, it being thought probable that bits of embryonal cartilage,
during the formation of the ear, become included in the salivary
glands.

[Footnote 79: _Volkmann's Sammlung klinischer Vortrage_, xcvii. 819.]

In like manner, Cohnheim explains the frequent occurrence of certain
epithelial tumors at the orifices of the body--the cervix uteri and
the vicinity of the tracheal bifurcation--not through the exposure of
these parts to injury, but because they are regions in which embryonal
irregularities of development are likely to arise.

That congenital, local peculiarities are an important element in the
origin of tumors has already been strongly advocated by Virchow. Not
only are children born with tumors, but instances of growths
eventually arising from birth-marks, and the occurrence of certain
tumors in the same locality in successive generations of the same
family, are sufficiently familiar.

Although certain tumors are admitted to be due to congenital
peculiarities of tissue, and even to represent atypical growths from
embryonal tissue, the theory of such an embryonal origin for all
tumors seems unnecessary. The resemblance in symptoms as well as in
appearance, and even in structure, of certain tumors to inflammatory
products, and their frequent association with these, has led to the
suggestion of an irritant as an exciting cause for the tumor, even in
the absence of local peculiarities of tissue. {108} It is obvious that
were the embryonal theory of origin, as extended by Cohnheim,
universally applicable, the growth demands something more than a focus
of embryonal cells. An immediate cause for their growth after a
dormant period, extending even into old age, is required. Cohnheim
finds such in a sufficient supply of blood. He attributes the
development or rapid growth of the tumor to this feature, and supports
his view by the usual appearance of exostoses when the skeleton is at
its period of most vigorous growth, and of dermoid cysts at a time
when the formation of the beard indicates active developmental
conditions in the outer germinal layer.

The growth of ovarian cystomata at and after puberty, and of these and
mammary tumors during pregnancy, are also explained on the ground of a
more abundant supply of blood at such periods. He and others find in
physiological conditions a source for the abundant blood-supply--that
is, the efficient nutrition for the growth of a tumor. The necessity
of sufficient nutrition in the development of tumors is universally
admitted, and its source may be looked for in pathological as well as
physiological conditions.

The existence of an irritant of some sort often seems probable, and,
although its absence is more frequently determined than its presence,
it is obvious that when present it may be overlooked. Although
traumatic irritants of considerable mechanical severity exist in but a
small percentage of tumors, their occasional influence in the
production of morbid growths is not to be denied. Their action may be
explained as producing a congestion or as enfeebling the opposition of
physiological tissues to pathological growths. The importance of an
irritant as the exciting cause, however its action may take place, is
supported not only by the sequence of injuries and tumors, but also by
the frequent occurrence of tumors in parts exposed to injury and
irritation. Such exposure may result from position, structure, or
function. The orifices and prominences of the body, the retained
testis in the inguinal canal, are notoriously liable seats of tumors.
Soft, friable, and slightly resistant structures, like mucous
membranes, are not only the frequent place of origin of tumors, but
the most exposed parts of such structures are oftenest affected. The
exposure resulting from function is manifest by the relation presented
by the periods of greatest functional activity of the growth of tumors
in such organs as the mammary gland, uterus, and ovaries.

The importance of an irritant is still further suggested by the
association of tumors with inflammation. The growth of tubercles and
cancer from serous membranes is frequently accompanied by an acute
inflammation of the latter; fibrous tumors and chronic interstitial
inflammations often coexist, while elephantiasis is usually preceded
by recurrent, erysipelatous inflammation of the skin.

The recent discovery of infective organisms as an exciting cause for
many of the members of an entire group of tumors, the granulomata, has
resulted in making prominent the etiological rather than the
structural features of the tumors concerned.

Local peculiarities of tissue, whether congenital or acquired, are
thus regarded as representing the beginnings of the growth. With the
multiplication of the cells their transformation may take place or a
change in their grouping may arise. The essential condition in the
production {109} of the morbid growth is that the formation of the
cells should take place at an abnormal time or place and should
progress in a normal or abnormal manner.

The growth takes place with greater or less rapidity in one or another
direction according to the nature of the tumor and its seat. The more
closely the tumor resembles the normal structures of the body, the
slower is its growth; the more it differs in composition, the more
rapid is its progress. This difference may arise from a predominance
of cells over intercellular substance, as in the case of the sarcoma,
or it may result from an atypical combination of tissues, as seen in
the development of epithelium and connective tissue in cancer.

The seat of the tumor is of importance mainly on account of the
vascular supply of a part and the more spongy or yielding nature of
certain regions. That the more abundant the nutrition of certain
regions of the body, the more favorable the opportunities for growth,
may be admitted without question. The spongy nature of tissues implies
a predominance of cavities over solid constituents. These cavities are
lined by surfaces which represent, on the one hand, the walls of
lymph-spaces, on the other the free surfaces of the body exposed to
the air, as the mucous or cutaneous surfaces and the pulmonary
surface. The rapidity of growth in the direction of the least
resistance is amply shown in the projection of tumors above the
surface of serous membranes and the frequent presence of fungoid
excrescences in various parts of the body.

The growth of tumors extends in all directions, but a distinction has
long been drawn between the concentric or interstitial manner of
growth and the excentric or infiltrating form. This distinction is
based upon the presence of a sharply defined limitation of
pathological and normal tissues or upon the absence of such a
limitation. Such a distinction is merely of relative importance, as
certain tumors may grow in both ways. This is best observed in those
bulging superficial tumors whose base is irregularly extended into the
continuous healthy tissues.

The concentric variety of growth includes those tumors which have
commonly been described as encapsulated, and which are capable of
ready enucleation from their surroundings in virtue of a thin layer of
loose connective tissue lying between the tumor and the contiguous
tissue. Such a capsule represents the matrix, the pia mater, in which
lie the blood-vessels going to and coming from the tumor, and is often
nothing else than the distended and hyperplastic fibrous tissue
remaining after the absorption of the muscular fibres or gland-cells
from the tissues surrounding the morbid growth.

The excentric, peripheral, or infiltrating extension of the tumor
takes place when the surrounding parts are invaded by the active
elements of which the tumor is composed. The amoeboid property of the
cells of certain tumors is well known, and the possibility is
admissible that the indifferent cells of the body, so often
accumulated at the periphery of the growth, become impregnated with a
formative function by the constituents of the tumor. Such amoeboid and
wandering cells represent a means through which the growth of the
tumor may become extended in its vicinity as well as in more remote
parts of the body.

The extension in the vicinity may be continuous or the reverse, the
latter through the formation of secondary nodules, which may {110}
eventually become fused with the primary mass. The continuous growth
takes place, as has been more particularly shown by Koster, along the
lymph-channels surrounding the tumor, which may become filled,
distended, and eventually obliterated by projections from the
neoplasm. Both methods of peripheral growth, by secondary nodules and
continuous extension, represent an infection of the surrounding
tissues, especially if it be admitted that the cells through which the
increase is accomplished are direct descendants of the pre-existing
cells of the part. Not only does the extension take place through the
lymphatic vessels about the tumor, but blood-spaces as well as
lymph-spaces may be invaded. Thrombi are then found whose structure is
frequently that of the tumor, and whose connection with the same is
direct through the perforated wall of the vessel. These features in
the growth of tumors lead directly to the consideration of the means
by which multiple tumors appear in remote parts of the body after a
single tumor has appeared in a given locality, and after the removal
of such a primitive growth.

The distinction between primary and secondary tumors is now so obvious
that one is inclined to forget that the presence of numerous tumors at
various parts of the body was at one time regarded as evidence of the
constitutional or dyscrasic nature of the morbid growth. Such a
multiplicity seemed to indicate that the blood was charged with the
constituents of the tumor, which were deposited at various parts of
the body.

Although certain multiple tumors may be present in different
localities without an apparent relation between an antecedent and a
subsequent growth, such tumors are usually limited to certain systems
of the body. Multiple bony tumors are found growing from bones,
fibrous and warty tumors from the skin, and fibro-myomata from the
uterus. Cohnheim's theory of the embryonal origin of tumors may seem
applicable in such cases, but the frequent association of the
osteomata with chronic inflammatory conditions, of cutaneous warts and
fibrous tumors with local irritative processes, makes such a
hypothesis unnecessary.

Those tumors whose multiplicity is of the greatest clinical importance
are the rapidly growing forms terminating fatally. Such are those
which reappear in the scar after the removal of a cancer, or in the
adjoining chain of lymphatic glands or at remote parts of the body.
The most satisfactory explanation of their presence, and of the
generalization, recurrence, or metastasis of tumors, is derived from
what has already been stated with reference to the manner of the
growth of the latter.

It is well known from experiments on animals that various living,
normal tissues when transplanted to remote parts of the same
individual or to other individuals may continue to grow. Cohnheim
claims, as has been previously stated, that a distinction is to be
drawn in this respect between the tissues of the adult and the foetus,
where the genesis of tumors is concerned. This observer, in connection
with Maas,[80] has found that the transplanted material (periosteum),
although growing for a while, disappears at the end of five weeks, and
it is asserted that fragments of tumors, when transferred, suffer a
similar fate. Wile,[81] on the contrary, {111} who has experimented
with reference to the fate of transplanted tissues and portions of
tumors, reports that one hundred days after the transfer of periosteum
the lung was found to contain several centres of ossification. He
regards the latter as proceeding from the fragments of periosteum
introduced into the jugular vein, and his results thus widely differ
from those of Cohnheim.

[Footnote 80: _Virchow's Archiv_, 1877, lxx. 161.]

[Footnote 81: _The Pathogenesis of Secondary Tumors_, reprint from
_Philadelphia Med. Times_, July, Aug., and Sept., 1882.]

Notwithstanding the numerous experiments which have been made in
various parts of the world to excite the growth of transplanted bits
from tumors, most of them have terminated unsuccessfully. Although a
temporary growth of fragments of tumors has taken place after
transplantation, their eventual disappearance has usually occurred.
Cohnheim lays stress upon this fact in connection with his theory of
the origin of tumors. He considers that the fragments of tissue and
tumors disappear in consequence of the inability of the foreign
particles to withstand the metamorphosis of physiological tissues. If
this opposition is neutralized, the existing germs of tumors become
capable of development. Wile, however, found that eight weeks after
the introduction of a bit of cancer into the lung of an animal the
fragment had increased nearly twice in size. He also refers to the
positive experiments of Newinsky,[82] who transplanted a bit of cancer
from a dog to the subcutaneous tissue of another, young dog, and
found, after five months, not only an ulcerating cutaneous cancer at
the place of inoculation, but also a metastatic nodule of the size of
a hazel-nut in an axillary lymphatic gland.

[Footnote 82: _Allgem. medicinische Central-Zeitung_, 1876, lxxi.
875.]

For the present consideration it may be borne in mind that fragments
of normal (foetal) tissues, as shown by the experiments of Zahn and
Leopold, when introduced into the organs of animals, may become
enlarged. It is also certain that bits of tumors, after their
introduction into the tissues and organs of animals, have become
increased in size. What their eventual fate might have been does not
appear; and herein lies the weak point of the experiments with
reference to the production of secondary tumors. For such experiments
to be regarded as crucial it is necessary that a large number of
previously healthy animals, after inoculation with fragments of morbid
growths, should present in various parts of the body well
characterized tumors whose structure should be like that of the
particles introduced.

The experiments above referred to are of value in confirming the views
concerning the generalization of tumors which have been generally
admitted since Virchow's discoveries with regard to the phenomena of
embolism.

Tumors are said to become generalized when they appear not only in
various systems of the body, but in various organs and tissues. They
are found usually in considerable numbers, and with such differences
in size, shape, and appearance as to indicate different ages. Such
tumors are regarded as arising directly or indirectly from a common
source. This source is called the primitive or primary tumor, and its
derivatives the secondary tumors. The latter are usually considered as
the direct descendants of the former, although their relation may be
that of several successive generations.

The primitive tumor in its growth may extend into lymphatics and
blood-vessels, as has already been suggested. Such an extension may be
{112} so little obvious when the tumor is removed by the surgeon that
all diseased tissues are apparently separated from the body. A
recurrence of the tumor is said to take place when the growth returns
in the cicatrix, frequently in a multiple form. The explanation of
such a recurrence is based upon the probable presence, at the time of
the operation, of fragments of the tumor within the tissues forming
the base and edges of the wound. During and after the healing of the
wound their growth is supposed to continue till they become apparent
as small tumors. The progress of these recurrent tumors is at times
extremely rapid, and they may attain a considerable size in the course
of a few weeks. Such nodules are secondary in point of time, although
they were actually a part of the primary growth.

Secondary nodules in descent as well as time are those which appear at
distant parts, often after the discovery of the primary tumor. Such
nodules are regarded as resulting from the transfer of particles of
various size from the primitive growth, either through the
lymph-vessels or blood-vessels. If the invasion of the body takes
place through the former, the fragments may be floated along to the
nearest lymphatic gland, where it remains when too large to pass
through. If it retains the capacity of growth or of stimulating a like
growth, there results a more or less complete transformation of the
gland into a morbid tissue like that from which the fragments came.
Adjoining lymph-glands may become infected from the first, until
eventually an entire series becomes more or less completely
transformed into morbid growths. A like invasion of the lymphatic
glands may take place through a continuous extension along the
lymph-vessels; and it is not rare to find the sub-pleural or
sub-peritoneal lymphatics as an elevated meshwork in consequence of
the neoplastic growth within them. Such a method of extension may take
place when a cancer of the stomach or liver is associated with a
cancer of the pleura, the intervening lymphatics of the diaphragm
offering a direct and continuous communication.

With the outcropping of a tumor upon a serous surface the possibility
of the detachment of particles is at hand. These may become
transplanted to the opposed serous surface or may be transferred to
the most dependent parts, and there serve as seed for subsequent
growth.

The probability of the embolic nature of many secondary tumors was
early suggested in the history of embolism. Rapidly growing tumors
were known to be capable of perforating the walls of adjacent
blood-vessels, especially veins, and to continue growing along the
course of such vessels. The possibility of the detachment of portions
of these tumors and their transfer along the course of the circulation
was an inevitable inference from the results of experimentation with
foreign bodies. Cancerous emboli were thus recognized as a possible
variety, and their distribution was subject to the same laws as those
governing emboli otherwise constituted. Multiple nodules were
frequently found in the lungs in connection with tumors growing into
the inferior vena cava, while multiple nodules in the liver were
usually associated with tumors of the gastro-intestinal canal or other
regions whose vessels formed a part of the portal circulation. The
readiness with which portions may be detached after death from the
soft masses projecting into the interior of veins suggests the ease
with which particles may be {113} separated during life. The
experiments already referred to show that isolated fragments of tissue
serving as emboli may grow in the place of their reception, and it is
presumable that the resulting growth takes place under the same
conditions as those prevailing at the place from which the embolus
started. The question whether the secondary tumor arises from the
reproduction of elements transferred from the primitive disease, or
whether these excite a characteristic, specific growth of the cells in
the place of their retention, may still be regarded as open. The
experiments favor the former view, and they alone are capable of
satisfactorily determining the point in question.

The secondary nodules, whatever may be their method of origin, present
the peculiarities of the primitive growth. If the cells of the latter
are pigmented, those of the former show the same peculiarity. If the
structure of the primitive tumor contains bone, cartilage, or squamous
epithelium, the secondary growths show like characters, though they
may be present in the heart or other organs where such tissues are not
present as normal constituents. So constant and characteristic is this
feature that the structure of the tumor is usually as well displayed
in the examination of the secondary as of the primitive nodule.
Indeed, the structural peculiarities of the growth may be more
characteristically shown in the former in those instances where the
primitive tumor has undergone degenerative changes obscuring its
histological features.

The tissues of the tumor are subject to the various changes which take
place in the normal tissues of the body. Their growth is attended with
a multiplication of cells and a formation of intercellular substance.
Tumors whose growth is the most rapid are those whose blood-vessels
are the most numerous and whose relation to the cells is most
intimate. The slower the advance of the tumor, the more permanent is
it likely to become, while the more rapid the progress, the more
transitory are its elements. The growth may continue, and yet the
actual size of the tumor may diminish through the absorption of its
degenerated parts. The cells of the neoplasm may undergo fatty
degeneration, or they may become cornified. They may undergo the
mucous metamorphosis or the amyloid and colloid degenerations. They
may take up pigment or they may produce the same. The intercellular
substance varies in its character as does that of normal tissues. It
may be slimy, homogeneous, or fibrillated. It may contain mucin,
chondrin, or gelatin, and may be infiltrated with calcareous salts.
Limited necroses with characteristic cheesy appearances are of
frequent occurrence.

Tumors may become the seat of inflammatory processes, indicated by
suppuration and fever, which may result in abscess or gangrene, or
their progress may terminate in the production of scars. Ulceration
may occur in consequence of the extension of an inflammatory process
to the surface, or it may result in the course of the degenerative
softening of a tumor. In both cases the cutaneous or mucous surface is
involved and destroyed, and the interior of the tumor being exposed
putrefactive processes, with fistulae and sinuses, arise, the latter
favoring the retention of the product and the persistence of the
inflammatory process.

Tumors are always pathological, but the resulting disturbances vary
within wide limits and are often of a complex character. The familiar
distinction between benignant and malignant tumors is based chiefly
{114} upon this variance in the nature of the disturbances. Those are
benignant which closely resemble the normal structures of the body,
increase but slowly, and, if they attain a large size, produce mainly
mechanical disturbances. They may prove serious, even fatal, if so
seated as to interfere with the function of important parts of the
body. Very large and heavy tumors may prove burdensome solely on
account of their weight, while others of similar character, elsewhere
seated, may interfere with respiration or circulation, and eventually
with nutrition. Tumors in exposed situations may become important only
in virtue of their liability to injury, while others impede the
function of a part or an organ by pressure upon its nerves and vessels
or by obstructing its ducts.

The malignant tumors, on the contrary, differ in their structure from
the normal tissues of the body. Their growth is rapid and infiltrating
rather than slow and concentric. Such tumors usually have a
predominance of cells and thin walled blood-vessels. The former may be
little else than nuclei enveloped in an easily destructible
protoplasm, or they may be composed of multi-nucleated masses of
protoplasm, and are then known as giant-cells. The most malignant
tumors are those which tend to become generalized as well as to spread
locally. They recur locally, and appear in the nearest lymph-glands
and at remote parts of the body. The disturbances produced by the
malignant tumors depend less upon their mechanical relations than upon
their tendency to destroy tissues and disturb functions. With their
presence and progress in vital organs there is associated, from their
manner of growth, a destruction of the cells of such organs, as the
kidneys and liver, the lungs and heart. When they are seated in the
spleen and lymphatic glands, a disturbance in the blood-making process
must be associated. Their occurrence in the alimentary canal opposes
the admission, digestion, and expulsion of its contents, and produces
disturbances varying as to the seat and peculiarities of the tumor.
The progress of the malignant tumor is often associated with
ulceration, watery discharges, and hemorrhage. The frequent
coexistence of emaciation, weakness, anaemia, and a yellowish
discoloration of the skin forms a group of disturbances which,
included under the name "cachexia," have long been prominent as
significant of malignant tumors. At the present day this cachexia is
regarded rather as the result than the cause of the tumor, whereas
formerly the reverse was the case.

The modern classification of tumors is based chiefly on their
structure, in part upon their method of origin, and in part upon their
cause.

With the observation of the similarity of appearances in the flesh of
which the external and internal neoplasms are composed, the suggestion
readily presented itself to regard the external tumors and the
internal growths as similar in character. External forms, physical
characteristics, clinical peculiarities, all proved insufficient as a
means of identifying the two, and the step was a short one which led
to the minute study of the flesh of the tumor and a comparison of its
resemblances and differences. This comparison obviously included a
knowledge of the structure and peculiarities of normal tissues. As
histological studies advanced, so did the pursuit of pathological
histology, and the tumors which were once designated as encephaloid,
mastoid, pancreatoid, or nephroid, from real {115} or fancied
resemblances to certain organs of the body, became analyzed into their
microscopic rather than macroscopic characteristics.

It is unnecessary to say that the modern classification of morbid
growths owes its foundation and a large part of its superstructure to
Virchow, whose classic work, _Die Krankhaften Geschwulste_, showed the
direction which future investigators were to pursue and the nature of
the discoveries likely to result.

The tumor represents the result of the growth of a tissue or tissues
which are like or resemble those which form the normal constituents of
the body. Although a new formation is present, it is composed of
tissues lying within the possibilities of the individual. A new
formation of feathers, as Virchow suggests, is beyond the productive
powers of human tissues, though within those of feathered animals. A
goose can produce a tumor containing feathers, not one in which hairs
are found; in the human species tumors containing hairs may occur, not
those, however, in which feathers are present. Although the cells of
the tumors of man may deviate in their appearances from the cells of
normal tissues, this deviation is never so extreme that their analogue
cannot be met with in some part of the body.

As the normal tissues originate from pre-existing tissues, so the
pathological tissues of the tumor grow only from the antecedent
tissues. The matrix from which the tumor arises is a normal tissue.
There is produced from it, as a neoplasm, either a tissue which
follows the type of the maternal tissue, a homologous tumor, or one
which deviates in type from that of the matrix, a heterologous growth.
Although the latter differs in its composition from that of the
matrix, it does not vary essentially from a like tissue to be found
elsewhere in the body. It occurs where it does not belong either in
place, time, or quantity. The homologous tumor appears rather as a
hypertrophy of the tissue from which it arises, and the line between
this variety of growth and a simple hypertrophy is often purely
arbitrary.

Although tumors, in the more limited sense, are solid, fleshy masses,
the new formation of tissues may result in the presence of a tumor
within which is a cavity with various contents. Such a cavity is not a
mere hole, but has a distinct wall of connective tissue lined with
epithelium or endothelium. A distinction is thus drawn between cysts
and growths--one which is of daily importance in the practice of
medicine--and Virchow's oncology includes the consideration of the two
varieties of tumors.

Cystic tumors are subdivided according to the nature of their contents
and the method of their origin. One group is composed of clotted blood
within cavities resulting from the laceration of tissues or in
preformed spaces. If the cyst primarily is merely a rent, the wall
becomes thickened in time from a growth of the limiting tissues, and
the blood-clot, of which the tumor was chiefly composed, may remain or
become absorbed. If the latter event occurs, its place of deposit may
become obliterated by a fusion of the walls of the cyst, or may
persist from the subsequent addition of serum.

The cystic tumor whose contents are extravasated blood is the
haematoma, familiar instances of which are met with in the haematoma
of the dura mater, of muscle, of the vulva, and the polypoid haematoma
of {116} the uterus. The latter is the long retained and constantly
enlarging blood-clot, due to the adherence of portions of the placenta
after childbirth.

The second group of cystic tumors has for its contents a more watery
fluid, and to this the term hygroma is applied. This watery fluid
lies, for the most part, within preformed cavities, and its
accumulation is connected with a dilatation of these cavities.
Instances are met with in the tumors resulting from the accumulation
of fluid in the membranes of the brain or spinal cord, and in the
ventricles of the former or in the central canal of the latter. These
lead to the congenital cystic tumors of the cranium or spine, with
watery contents. The ganglion, the house-maid's knee, as also the
hydrocele of the tunica vaginalis, are regarded as hygromata. The
hydrocele of the neck and elsewhere in the subcutaneous or
intermuscular connective tissue is now removed from the hygromata to
the tumors which arise from lymph-vessels. A like transfer of other
hygromata might be made in accordance with the prevailing views
concerning the cavities in which the watery fluid is accumulated.

A third group of cysts contains material which represents essentially
a production from the wall, with a difference of composition dependent
upon the nature of the wall. Such cysts give rise to tumors through
the retention of their contents, and they are called retention-cysts
or retention-tumors. In the wall of the cysts is a gland-tissue, which
may line the surface or lie beneath. The glandular structures may be
cutaneous, mucous, or represent a part of the great glands of the
body, as the liver and kidneys. The atheromatous cyst of the skin, the
mucous cysts of the gastro-intestinal mucous membrane, and the ovula
Nabothi of the uterus are examples of the retention of secretion
within glands. The dropsical dilatations of the antrum, the vermiform
appendage, the uterus, the biliary and renal canals furnish instances
of tumors resulting from the retention of secretion on a large scale.
In the subsequent history of these retention-cysts the secretion may
be modified chemically and physically; the cells upon the walls may be
transformed from columnar forms into flattened and scale-like
varieties. In time, the original secretion frequently becomes a watery
fluid, resembling the contents of the hygroma previously mentioned.

This grouping of cysts in contradistinction to fleshy tumors omits the
consideration of a series of cystic tumors of enormous size, the
multilocular tumors of the ovary. This class represents a more complex
form of cystic growth--one whose tendency is toward the reproduction
of cysts, to which the term cystoma is applied. The cystoma is the
result of an active new formation of epithelium and connective tissue,
and is classified as a variety of the epithelial group of tumors.

Morbid growths, as distinguished from cysts, are divided by Virchow
into the simple and complex forms. The former consist of a single
tissue, the histoid tumors; the latter of several tissues suggesting
an organ, the organoid tumors; while still others, in which the number
and grouping of tissues is so complex as to simulate systems of the
body, even monstrosities, have received the term systematoid or
teratoid tumors.

Virchow claimed that the growth of most tumors took place from the
connective tissues, and that most of the organoid tumors, especially
cancer, arose from the formative action of the connective tissue in
the part where {117} it first made its appearance. The structure of
cancer suggested an organ, as it consisted of collections of cells
resembling epithelium, within spaces or alveoli whose walls were
formed of connective tissue. The epithelioid cells of the cancer, as
well as the connective-tissue corpuscles, were considered to arise
from pre-existing cells of connective tissue.

The first, most important, modification of Virchow's views, which has
led to a more rational appreciation of the relation of the various
tumors, especially of the epithelial group, to each other, arose in
consequence of the investigations of Thiersch and others with regard
to the origin of certain cancers. This observer[83] claimed that the
epithelioid element of cutaneous cancers arose in all instances from
pre-existing epithelium, either of the rete mucosum or cutaneous
glands. Similar views were suggested, with various degrees of
precision, by other authors concerning certain cancerous tumors
elsewhere, but were first applied to all cancers with a more exact
formulation by Waldeyer,[84] to whom the prevailing views with regard
to the histogenesis of morbid growths are due. According to him, the
essential (epithelioid) element of all primitive cancers arises from
pre-existing epithelium; consequently, no cancer-cell can arise except
in organs where epithelium is normally present.

[Footnote 83: _Der Epithelial Krebs, namentlich der Haut, etc._,
1865.]

[Footnote 84: _Virchow's Archiv_, 1867, xli. 470; 1872, lv. 67;
_Volkmann's Sammlung klinischer Vortrage_, 1871, xxxiii.]

This comprehensive statement was rendered possible by the
embryological researches of Remak at the outset, and afterward by
those of His and Waldeyer. Remak showed that after differentiation of
the cells of the ovum into the several germinal layers, those from one
layer could not serve to originate the cells belonging to another
layer. The development of normal tissues takes place within the limits
defined by this differentiation. Epithelium thus is not derived from
connective tissue, nerves, or muscles, nor was the reverse known to
occur. To His is due the exact appreciation of the superficial cells
of serous membranes, which had been previously called epithelium, and
had thus been confounded with the epithelial cells of mucous or
cutaneous membranes and of secretory glands. He showed that these
cells had a wholly different origin from epithelium, and were simply
scale-like cells of fibrous tissue, to which he applied the name
endothelium. The latter is now used as the term for the thin, squamous
cells of fibrous tissue, whether they are found lining the walls of
the great serous cavities or the smaller lymph-spaces, the
endocardium, or the inner coat of blood-vessels and lymphatics.

The importance of this distinction is obvious when the occurrence of
tumors, called cancers, is observed in parts which contain no
epithelium. Aside from the vagueness of the term cancer, as applied
clinically, tumors are sometimes met with, even in parts where
epithelium normally does not exist, whose structure resembles more or
less closely that of cancer as usually recognized. Such tumors are to
be regarded as of an endothelial rather than epithelial character, and
as such their histogenesis falls under the general laws of the
development of tissues.

Waldeyer[85] has suggested that the primitive basis for the
development of the genito-urinary tract contains cells which are
equivalent in their possibilities of ultimate development to the
epithelium of the limiting germinal layers--a suggestion which is of
importance in permitting the {118} epithelial tumors of the ovary to
be brought under the general embryological laws of development.

[Footnote 85: _Eierstock und Ei_, 1870.]

As the growth of embryonal tissues is so defined that descendants are
like their ancestors in all respects, so the development of tissues in
the adult is regarded as defined with equal precision. Eberth and
Wadsworth[86] have shown that the regeneration of corneal epithelium
takes place from pre-existing epithelium. E. Neumann and others claim
in like manner the development of muscular tissue from antecedent
muscular cells.

[Footnote 86: _Virchow's Archiv_, 1870, li. 361.]

The relation of cancer to epithelial tumors is regarded as similar to
that borne by sarcoma to tumors composed of connective tissues. The
growth of the epithelial elements into the neighboring parts is
through paths determined by pre-existing or new-formed connective
tissue. The active element of the cancer lies more especially in its
epithelioid cells, and its growth takes place in an atypical rather
than a typical manner. Of the various epithelial tumors, there are
those like the cutaneous horn or corn, the adenoma or cystoma, whose
epithelial growth takes place in accordance with normal methods of
production. The epithelioid constituent of the cancer, on the
contrary, grows often with great luxuriance and with but little
tendency to carry out the normal mutual relations of the epithelium
and connective tissue of the part from which it proceeds. The
epithelioid masses or sprouts are composed of cells whose relation to
each other resembles that of normal epithelium in the absence of an
intercellular substance, while the shapes of the cells correspond more
or less closely with that of the epithelium in the region from which
the tumor arises. The epithelioid cells of cutaneous cancers resemble
those of the surface, the rete, or the glands of the skin. Cancers of
the stomach or uterus contain epithelioid cells whose shape simulates
the varieties in the stomach and uterus. Such resemblances are carried
out in the degenerations which the cells of cancer undergo. The
horn-like, keratoid, transformation of epidermoid cells in cutaneous
cancers, the mucous degeneration of the epithelioid cells of cancers
of mucous membranes, are sufficiently familiar. Notwithstanding these
resemblances, which are also present in secondary tumors at remote
parts of the body, the epithelioid growth advances without limit and
without reproducing the normal type. Cancer is therefore defined as an
atypical, epithelial new formation.

Sarcoma, on the other hand, whose clinical features correspond so
closely with those of cancer, simulates, as shown by Virchow, the
connective tissues. It is composed of cells and intercellular
substance, both of which may be as varied as are those of the
connective tissues. The shape of the cells is as diverse and their
contents as various, while their possibilities of degeneration are
alike. The cells of the sarcoma are not simply cemented together, as
are epithelial cells, but they are separated from each other by an
intercellular substance, which corresponds in its appearance and
chemical properties with that of mucous, fibrous, cartilaginous, or
osseous tissue. The structure of the sarcoma differs from that of
these tissues in presenting a predominance of cells over intercellular
substance, while the reverse is the characteristic of most varieties
of connective tissue. In this predominant cell-formation lies its
absence of type, {119} whereas the atypical character of the cancerous
growth is manifested rather by the irregular grouping of the cellular
masses than by an abundance of cells.

As the original cancer is considered as possible only in parts where
epithelium is a normal constituent, so the primitive sarcoma is
possible only in parts where connective tissue is present. The
apparent great frequency of sarcoma in recent times is thus obviously
explained. With an agreement as to its histological characteristics,
its possible place of origin is any of the connective tissues of the
body, and their presence is universal. In the manner of its growth,
its recurrence, and generalization it is subject to the same laws
which determine similar events in the history of cancer. Its
degenerations are often the same, and its symptoms are due to the
action of like causes.

The importance of distinguishing between these atypical tumors is
real, in that it is only through the association of causes, symptoms,
and results with defined and constant characteristics that a practical
knowledge of tumors is to arise. The time-honored distinction between
malignant or semi-malignant and benignant growths is always to be
sought for, and can only be fully possessed when the natural history
of the new formations is known. With an exact appreciation of the
structure of a tumor it becomes possible to study its special
pathology. From a knowledge of the latter are to be derived those
features of importance in determining the relation of morbid growths
to other deviations from normal and physiological processes. An
immediately practical benefit arises from the Thiersch-Waldeyer
modification of Virchow's theory of the origin of tumors, in that it
permits with greater ease a more accurate clinical diagnosis.
Lucke[87] has been prominent in calling attention to the suggestions
thus presented.

[Footnote 87: _Volkmann's Sammlung klinischer Vortrage_, 1876, xcvii.]

The diagnostic value of the theory above-mentioned is rather negative
than positive. With rare exceptions, a tumor cannot be epithelial in
character if its origin is from an organ or a part in which epithelium
is absent. The possible exceptions admit theoretical explanations
which present considerable degrees of probability, and are also based
upon the existing views of the development of tissues.

A tumor whose origin from the connective tissues is determined
partakes of the characteristics of its matrix, and is a
connective-tissue tumor. Its development from fibrous tissue is more
likely to result in a fibroma; from fat tissue, a lipoma, or a myxoma;
from cartilage or bone, a chondroma or osteoma.

Tumors developing at certain periods of life in certain parts of the
body are more likely to belong to one than another of the histogenetic
groups. Tumors of the connective-tissue series are stated by Lucke as
more prevalent before the age of thirty-five years, while those of the
epithelial group are more likely to occur after this age, and cancer
of the lip is of special frequency in old age. The fibro-myoma is of
most frequent occurrence in the uterus, and rarely attains a large
size till the approach of the climacteric.

The rapidity of growth of tumors is also associated with their
genesis. It has previously been stated that the more rapidly growing
tumors are those whose cells are most abundant and in the closest and
most {120} intimate relation to blood-vessels. The type of such tumors
is the sarcoma with its scanty intercellular substance, while the
other (histoid) tumors in the same series, as the fibroma, lipoma,
chondroma, etc., are of relatively slow growth. Tumors of the
epithelial series are of slow growth, from the constantly increasing
distance of the new-formed cells from the vascular connective tissue
which provides their nourishment. When, however, the growth of the
epithelium advances into the connective tissue, pushing out in all
directions and coming in contact with new series of vessels, the
opportunities for nutrition are favorable. In like manner, when the
new formation concerns the connective-tissue stroma, as well as the
epithelial sprouts, vascularization proceeds with the development of
the tumor, and favorable conditions for rapid growth are presented.
Large epithelial tumors may thus arise within organs, but, as the
surfaces are reached, the sources of nourishment become farther
removed and the degeneration of the epithelium favors its detachment
and the formation of ulcers. Hence the tumors whose advance is
associated with ulceration belong rather to the epithelial than the
connective-tissue group.

The tendency of the cancerous tumors to become generalized through the
lymphatics, and that of sarcomatous growths through the blood-vessels,
is admitted as an important feature in the differential diagnosis.
Although there are numerous exceptions, the rule is available. Its
explanation is based upon the assumed inability of the larger
epithelial cells of the cancer to pass through the lymph-glands; being
detained, they serve as new centres of growth. The smaller cells of
the sarcoma, on the contrary, are permitted a passage through the
gland. The numerous and thin walled blood-vessels present in the
rapidly growing sarcoma permit an extension of the latter into their
interior, and thus a ready opportunity is offered for the formation of
emboli.

Another important modification in the classification of tumors has
resulted from the recent discoveries regarding the nature and effects
of infective agencies. Virchow grouped together under the term
granulomata certain growths composed of granulation-tissue occurring
in syphilis, lupus, leprosy, and glanders. Their relation to
inflammatory processes was very intimate, yet they were recognizable
as tumors from their possession of many of the characteristics
generally admitted as belonging to such morbid growths. Although at
times their presence might be regarded as evidence of an inflammatory
disturbance, their frequent appearance independently of general
symptoms of the latter was apparent. These tumors, furthermore, were
so frequently accompanied by inflammatory products as to suggest a
like cause for both. Virchow stated that the recognition of the
etiology of these tumors was indispensable to their separate
consideration, and laid stress upon the presence of a specific virus,
contagious and infectious, in the case of syphilis. His views
concerning the etiology of leprosy, though more guarded, yet carried
the suggestion of the importance of exact investigation concerning the
assumed contagious character of this disease. The contagiousness of
glanders was not only admitted, but the similarity of its manner of
origin and propagation to the invasion of syphilis was also stated.
Not only were the resemblances between glanders and syphilis
recognized, but lupus, leprosy, tubercle, and scrofula were also
admitted as presenting a similar relation.

{121} The importance of recognizing the etiology of these tumors
rather than their anatomy as a basis of classification was strongly
urged by Klebs,[88] who proposed the term infective tumors for the
group of granulomata, including syphilis, lupus, leprosy, and
glanders; and for tubercle, scrofula and the pearly distemper of
animals, which Virchow had classified as lymphomata. This group has
been still further extended by the addition of the lymphomata
occurring in typhoid fever, scarlet fever, and diphtheria. Ponfick[89]
has recently added the disease actinomycosis to the series, and
Cohnheim suggests that certain of the lympho-sarcomata may be
similarly classified.

[Footnote 88: _Prager Vierteljahrschrift_, 1875, cxxvi. 116.]

[Footnote 89: _Die Actinomykose des Menschen_, 1882.]

The growths thus included have a common element of structure--the
granulation-tissue, with its possible disappearance through absorption
or its transformation into an abscess or dense fibrous tissue. Such
features are those common to the granulation-tissue resulting from
ordinary inflammation. Their essential characteristic, however, lies
in the etiology of this granulation-tissue, and for many members of
the group the cause has been discovered to be microscopic organisms.
The constant presence of these is determined in sufficient numbers, in
such distribution, and in such relation, as to explain the nature and
occurrence of the tumors.

The evidence recorded is not equally full and exact for all members of
this group. Neisser[90] has discovered the bacillus of leprosy, and
the discovery by Koch[91] of the bacillus of tuberculosis, scrofula,
and pearly distemper has already been referred to. Schutz and
Loffler[92] have lately announced their isolation of the
micro-organism causing glanders, and Bollinger[93] discovered the
fungus whose presence is necessary for the existence of actinomycosis.

[Footnote 90: _Virchow's Archiv_, 1881, lxxxiv. 514.]

[Footnote 91: See page 99.]

[Footnote 92: _Deutsche medicinische Wochenschrift_, 1882, lii. 707.]

[Footnote 93: _Centralblatt fur die med. Wissenschaften_, 1877,
xxvii.]

In the above affections the organisms are to be regarded as the
characteristic active agent in producing the phenomena of the disease
in which they occur. The presence of micro-organisms in syphilis,
typhoid fever, scarlet fever, and diphtheria is admitted, yet their
absolute identification and constant presence as a cause of the
various manifestations of the respective diseases still remains to be
proved.

The classification of tumors herewith presented is essentially that of
Virchow, with such extensions and modifications as have arisen in
consequence of the investigations and discoveries during the twenty
years which have elapsed since the delivery of his memorable series of
lectures. Cysts are mentioned, as well as growths, from the importance
of the former in practical medicine. The frequent simultaneous
occurrence of cysts and growths in the same tumor should be mentioned,
and the cystic feature is usually indicated as a qualification.


CYSTS.

Cavities, either new formed or pre-existing, with various contents.
The latter are blood, liquid other than blood, and gland-secretion or
retained secretion. The wall varies in structure in accordance with
the method of origin of the cavity.

{122} _Haematoma._

A collection of extravasated blood, usually within the tissues.
Examples, haematoma of the pericranium (periosteum), of the external
ear, muscle, dura mater, ovary, broad ligament, vulva, anus, uterus
(from retained placenta), haematocele, dissecting aneurism.

_Hygroma._

A collection of transuded or exuded fluid in pre-existing or
new-formed spaces. Examples, hydrocele, hydromeningocele,
hydromyelocele, hydrencephalocele, ganglion, inflamed bursa.

_Retention-Cyst._

An accumulation of retained secretion in follicles or canals from
obstruction to its escape. Examples, atheroma and comedo of the skin,
mucous cysts of the gastro-intestinal mucous membrane, ovula Nabothi,
and cystic polypus of the uterus; retention-cyst of the antrum,
vermiform appendage, gall-bladder, and bile-ducts; dropsical
dilatation of the ovarian follicles, Fallopian tube, uterus
(hydrometra), parovarium (cyst of the broad ligament); hydronephrosis
and multilocular cystic kidney, spermatocele, ranula, galactocele.

       *       *       *       *       *

The growths are classified according to the tissues of which they are
chiefly composed and from which they originate, and according to their
etiology. There are consequently the connective-tissue group; that of
tissues of higher function, as muscle, nerve, and vessels; and the
epithelial group, in which the new formation of epithelium is the
essential feature. The teratoid group comprises a more complex massing
of tissues, representing a combination of those derived from all the
germinal layers of the embryo. The infective group includes those
tumors whose structure is closely allied to that of the products of
inflammation, but whose origin is the direct result of the
introduction from without of a microphyte.


CONNECTIVE-TISSUE GROUP.

Each member mainly composed of a more or less typical growth of a
connective tissue:

  Myxoma,
  Lipoma,
  Glioma,
  Chondroma,
  Fibroma (including papilloma and melanoma),
  Osteoma.

To these are added tumors composed of an atypical growth of a
connective tissue, chiefly manifested by a predominance of cells:

  Endothelioma,
  Sarcoma.

The sarcoma includes as many varieties as there are tissues in this
group, hence,

  Myxosarcoma,
  Liposarcoma,
  Gliosarcoma,
  Chondrosarcoma,
  Fibrosarcoma, melanosarcoma,
  Osteosarcoma.


{123} GROUP OF TISSUES OF HIGHER FUNCTION.

  Myoma, of striped (rhabdomyoma) and smooth (leiomyoma) muscular
    tissue,
  Neuroma, of nerve tissue,
  Angioma, of blood-vessels,
  Lymphangioma, of lymphatics,
  Lymphoma (?), of lymph-gland tissue.


EPITHELIAL GROUP.

Epidermis:

  Callus,
  Corn,
  Keratosis,
  Horn,
  Onychoma.

Epithelium of mucous membranes or glands:

  Struma (?),
  Adenoma,
  Cystoma.

In the above varieties the growth of epithelium is more or less
typical, a simple hyperplasia, either alone or combined with the new
formation of fibrous tissue. Only the last three members of the series
are tumors in the limited sense.


CANCER.

Cancer remains as an epithelial tumor, representing the atypical
growth of cells resembling epidermis or the epithelium of glands and
mucous membranes, extending into parts where epithelium is not found
as a normal constituent. A new formation of connective tissue is
usually associated with that of the epithelial cells.

Numerous varieties of cancer are described, according to the physical
and structural peculiarities of the tumor. The scirrhus and
encephaloid of the earlier writers are now transformed into fibrous
and medullary cancer. This change in name is due to the stress laid
upon the predominance of the fibrous stroma as the usual cause for the
hard, dense, scirrhous cancer, while an abundance of epithelioid cells
in relatively large alveoli is present in the encephaloid,
marrow-like, medullary variety.

When the growth takes place from the skin or mucous membranes, the
surface frequently presents numerous and usually arborescent papillae
or villi. The papillary cancers of the skin and the villous cancers of
mucous membranes are thus distinguished.

Cancerous growths of the skin and transitional membranes, often called
epithelioma or cancroid, usually contain epithelioid cells resembling
epidermis, and are therefore designated as epidermoid or
pavement-celled cancer. The alveolar contents of certain cutaneous
cancers are cells resembling those of the deeper layers of the rete
mucosum, while those of other cancers of the skin resemble rather the
epithelium of sweat-glands. Growths of the former character extend
laterally, ulcerate early, and are known as superficial cutaneous
cancer. They form one of the varieties of the so-called rodent ulcer.
Cutaneous cancers, simulating in their structure a reproduction of the
epithelium of sweat-glands, represent a variety of glandular cancer.
The latter term is applied to cancerous growths which arise in
glandular organs, with suggested resemblances of their cells to the
gland-cells of the respective organ. {124} Cylindrical-celled cancer
is frequently met with in those parts of which a cylindrical
epithelium is a normal constituent.

The degenerations of the epithelioid cells and stroma suggest
qualifying terms. The mucous and colloid cancers are those whose
alveolar contents or stroma have undergone a mucous or colloid
degeneration. The keratoid cancer is one which presents the horn-like
transformation of its epidermoid cells. The melanotic cancer contains
abundant pigment, melanin, within its cells.

These differences in the structure and appearance of the tumor are
frequently associated with certain modifications of growth and
clinical properties. The epidermoid cancers are less likely to recur
after early removal; the medullary cancers are of rapid growth and
prone to ulceration; while the fibrous or scirrhous forms are of
extreme slowness of growth. In general, however, the pathological
importance of cancerous tumors is essentially the same wherever the
seat and whatever the peculiarities of structure.


TERATOID GROUP.

Includes those tumors, usually of congenital origin and apparent at
birth, composed of connective tissue, epithelium, nerves, muscle, and
vessels. These tissues are often so grouped together as to suggest
systems of the body and parts of an individual. Cysts are often
present which simulate cavities found in the body, whether of normal
or pathological origin.

In this group are the dermoid cysts with their various contents,
epidermis, sebum, hair, teeth, and bone. The solid teratomata, with
all varieties of connective tissue, as fibrous tissue, fat tissue,
cartilage, bone, neuroglia, in addition to nerves, muscle, and
vessels. Squamous, cylindrical, and ciliated epithelium may be present
and line cavities, at times tubular, whose walls are formed of skin or
mucous membrane. Other tumors of this group are commonly included
under monstrosities, and comprise the varieties of duplication of
parts of the body, of which the extreme instances are such double
monstrosities as the Siamese Twins, Ritta and Christina, the Spanish
Cavalier, and the like.


INFECTIVE GROUP.

The chief characteristic is the cause, micro-organisms, which,
introduced into the body, produce, through their dissemination and
development, multiple growths of tissue like those resulting from
persistent inflammation. As their structure corresponds with the
productive results of inflammation, and their cause is analogous to
the infective causes of inflammation, these morbid growths are closely
allied to inflammatory disturbances. Their classification among tumors
is desirable, as they represent circumscribed growths whose
appearance, persistence, and effects closely resemble those
characteristics of the morbid growths, in the limited sense, in which
the new formation of tissue occupies a wider range:

  _Granuloma_ of tuberculosis, scrofula, leprosy, glanders,
    actinomycosis, syphilis, lupus.
  _Lymphoma_ of diphtheria, scarlet fever, typhoid fever.



{125}

GENERAL ETIOLOGY, MEDICAL DIAGNOSIS, AND PROGNOSIS.

BY HENRY HARTSHORNE, M.D.


ETIOLOGY.

Recognizing pathology as simply morbid physiology--that is, the study
of the body and its functions in states of disorder from morbid
conditions--how these morbid conditions are produced is the complex
question to be answered by Etiology.

Nor is this question (or series of questions) by any means only of
speculative or theoretical importance. It is, indeed, eminently
practical. What a difference, for example, there must be in the
diagnosis, prognosis, and treatment of an attack of inflammation of
the eye, in accordance with its causation by ordinary conditional
influences (taking cold), by a particle of steel imbedded in the
cornea, or by syphilis! How great the difference between the wound
made by the teeth of an animal, in one case with, and in another
without, the presence of rabies in its system! Take the instance of
what we call fever: at a certain stage it is almost the same in half a
dozen diseases. By the causation, when known, of this common congeries
of symptoms we judge of the essential nature of the malady, and so of
its proper treatment.

It is a maxim in philosophy that every event or effect must have at
least two causes. In medical etiology we often find many causes
conspiring to produce one effect. These may be, and commonly have
been, grouped together under two heads; as, 1, predisposing, and 2,
exciting, causes. But under each of these may come a number of
agencies contributing toward the production or modification of
disease. Thus, of predisposing causes we may enumerate inherited
constitution, habits of life, previous attacks of disease, atmosphere,
and other immediate surroundings. Exciting causes--say, of an attack
of apoplexy--may be, in the same case, mental shock, a stooping
posture, an over-heated room, etc. One disease is very often the next
preceding cause of another. So we speak of the great class of sequelae
of acute or subacute disorders; as, ophthalmia after measles, deafness
following scarlet fever, or blindness small-pox, abscesses following
typhoid fever, paralysis diphtheria, etc. But this kind of causation
is extremely common also in chronic affections. What a train of
organic troubles, of kidneys, heart, arteries, brain, and other parts,
attend the affection to which we give the name of Bright's disease!
How complex the sequence often of valvular disease of the heart,
itself in many instances the effect of rheumatic fever, with {126}
endocarditis as a local manifestation of that disorder! Hardly any
discovery in pathology (or pathogeny, the generation of diseases) of
the last half century has been more remarkable and fruitful than that
of thrombosis and embolism, with their serious and not rarely fatal
consequences, through obstruction of the blood-supply to different
organs.

Previous diseases constitute an often overlooked class of factors in
predisposing to new attacks, and also in determining their course and
results. Of some affections one attack prepares the way for another,
as is the case with intermittent fever, convulsions, delirium tremens,
and insanity. Just the reverse is true of yellow fever and of all the
exanthemata, as scarlet fever, measles, small-pox; likewise of the
analogous disorders, mumps and whooping cough. The moot question in
this regard concerning syphilis may be left for discussion elsewhere.

Our classification of the causes of disease may be set forth in simple
form, thus:

1. Pre-natal causation--viz. hereditary transmission of a proclivity
to certain disorders, and also the influence of circumstances acting
on either parent at the time of conception or on the mother during
gestation.

2. Conditional causation--_i.e._ that belonging to variations of
temperature, humidity, etc., affecting individuals.

3. Functional causation--that which is connected with excessive,
deficient, or abnormal exercise of any of the functions of the
economy.

4. Ingestive causation--_e.g._ bad diet, intemperance, poisoning.

5. Enthetic causation--viz. that of all contagious, endemic, and
epidemic diseases. Closely allied to this is epithelic morbid
influence--namely, that of the parasites producing certain affections
of the skin, as itch, favus, etc.

6. Mechanical causation. The effects of this belong chiefly, though
not exclusively, to the domain of surgery.

Pre-natal causation is of immense consequence, and its study takes in
the whole scope of the influences of species, race, family, and
individual parentage. Darwin's observations and speculations, and
those of other evolutionists, have not ignored the field of human life
in considering the struggle for existence and the survival of the
fittest. If we are obliged to admit that such a struggle and survival
do exist for men as well as for animals and for plants, it is
nevertheless obvious that either man's reason and will introduce
exceptions to the ordinary laws of development and selection in
nature, or else a very peculiar standard of fitness must be recognized
in the survivals of humanity. Many feeble, inert, deformed, and
diseased forms survive and perpetuate offspring through a long series
of generations, while strong and admirable ones perish, often even
destroying each other.

Leaving this theme, upon which biological science has not yet
pronounced its last word, we may inquire, What diseases are reasonably
ascribed to hereditary transmission? First, it must be remarked that
seldom is a disease actually received directly from a parent. Putting
aside a few asserted instances of variola and allied or analogous
affections in utero, congenital constitutional syphilis and (more
rarely) scrofulosis seem to afford almost the only examples of this.
Nearly always it is a predisposition merely that is inherited. This,
however, may be very strongly marked. Its seat is evidently in that
(as yet) occult law or {127} process of individual organic development
to whose manifestation we give the name of the constitution. In some
families all the men grow bald before forty; in others, scarcely so at
eighty. Some may expect deafness in middle life, others blindness in
old age, and others, again, have a probability of death from disease
of the heart at about fifty or apoplexy at about sixty years of age.
Such considerations enter into every examination for life insurance,
and they are no less important in our prognostications of the results
of diseases in practice.

Speaking more definitely, gout is undoubtedly often hereditary. That
is, a healthy childhood may be followed by liability to gout in adult
or middle age, even in the absence of direct provocatives to that
disorder, but much more frequently when they are present. Gout affords
an example of the general fact that inherited proclivity to special
diseases shows itself at nearly the same time of life in each
generation--scrofula in childhood, phthisis in adolescence or early
maturity, gout from thirty to forty, apoplexy after sixty, etc. But
exceptions to such rules are not at all rare. Gout also exemplifies
another important fact--viz. the occasional modification of the
transmitted morbid tendency or "diathesis." Parents who have regular
gout--_i.e._ painful attacks of acute inflammation of the smaller
joints, followed by deposits of urates, carbonates, etc.--not
unfrequently have children who are subject to neuralgia or dyspepsia
or modified rheumatic attacks (not sufficiently recognized in
practical treatises), to which the name "gouty rheumatism" is most
applicable. Again, in one generation there may be a marked tendency to
insanity; in the next, to paralysis; in a third, to tubercular
meningitis during infancy.[1] Or some of these successions may occur
in a reverse order.

[Footnote 1: For example, in one family known to me the grandmother
had paralysis, the mother died insane, and her three children all died
of tubercular meningitis.]

Constitutional syphilis is undoubtedly often conveyed by inheritance
from either parent. Sometimes the impression of this diathesis is so
intense as to devitalize the foetus in utero, causing still-birth. Or
the manifestations of the disease occur early in infancy, with
symptoms like those of the secondary or tertiary affection in the
original subject of it. Not often, indeed, is the exhibition, in some
manner, of inherited constitutional syphilis delayed beyond the time
of childhood.

Scrofulosis is well known to follow in the same family through
successive generations, in a manner apparently demonstrative of
hereditary derivation. It is true that here we have a problem not
without complication. Certain circumstances, as poverty of living,
dampness of locality, want of fresh air in houses, etc., promote
scrofula in children. Now, are we sure that it is from its parents
that each child, exposed to these morbific surroundings, has obtained
its disposition to strumous disorders? or may it not be that every
time the diathesis is thus originated de novo? It is to be answered
that decisive evidence in favor of inheritance is present in a number
of cases where the affection occurs so early in infancy as to be
almost or quite congenital in its beginnings; and in other instances
where removal of the parents into improved localities, and with better
living altogether, has not prevented the manifestation of the same
tendency in their offspring for two or three generations. The inquiry
does not differ very greatly in its nature from that concerning cases
of enthetic diseases--_e.g._ cholera, yellow fever, typhoid fever; as
to which the {128} succession of cases may be such as to allow
hypothetical explanation, either by transmission from one individual
to another or by the subjection of all to a common local infection or
epidemic influence. But in both sorts of cases crucial instances may,
with care, be found which determine at least the general etiological
law for each malady.

Pulmonary phthisis has been always considered to be, in a marked
degree, a hereditary disease, until, latterly, the hypothesis of a
tubercular virus has threatened to displace old views about it. If,
however, we accept the classification of cases of pulmonary
consumption approved by several leading pathologists, in which a
position is provided for non-tubercular phthisis, we may at least
place hereditary vulnerability, or proclivity to consumption, in this
category, while awaiting the final decision of science upon the real
nature and origin of tubercle. My own conviction continues to be
positive, that tubercular phthisis is often transmitted by
inheritance, in the same sense as other diseases are generally
so--namely, by the bestowal upon offspring of a constitution
especially liable to the occurrence of the disorder at the time of
life when it is generally most apt to appear. The investigations of
Villemin, Cohnheim, Schuller, Koch, Baumgarten, and others have given
(1882) much prominence to the idea of the possibility of the
transplantation of tubercle from one human or animal body to another.
Koch's elaborate experiments especially are asserted to have shown the
existence of a bacillus tuberculosis, a true, minute vegetative
organism, which can be cultivated outside of the body, in a suitable
material, at a temperature like that of living blood, and which, when
inoculated, produces tubercular disease. The discussion of this
subject will occur on a later page as a part of the general topic of
the causation of enthetic diseases.

Rickets occupies a much less prominent place in the experience of
American practitioners than in that of some countries abroad, and it
is therefore less easy here to obtain materials for the study of its
etiology. Among those who have had large opportunities for its
observation, opinion is divided very much in the manner above referred
to. Thus, Wiltshire and Herring assert it to be certainly hereditary;
Jenner denies this altogether, while Aitken adopts the ground that
predisposing causes are derived from the parents or the nurse, which
are so capable of influencing the health of the child as to lead in
course of time to the establishment of the disease.

Goitre is manifestly a family disorder to a large extent in certain
regions, most familiarly in Alpine valleys in Switzerland. But this
local feature takes us back to the same kind of question: Is it the
transmission of a specially modified constitution from parents, or the
direct action of morbid local influences on the children themselves,
that produces bronchocele and its frequent attendant, cretinism?
Undoubtedly, goitre often occurs in children of healthy parents
brought from another locality into one where the disease is common;
and, per contra, goitrous subjects not infrequently recover from the
affection when removed for a length of time from the place where it
was developed in them. We are, apparently, at least safe in taking
here a position like that of Aitken concerning rickets: viz. that
predisposing causes are derived from parentage, whereby, more easily
than in those of different descent, certain influences will develop
goitre or cretinism, or both together.

{129} As to leprosy, there seems no more room for doubt that it is
often--nay, generally--hereditary. The obscurity attending its
history, however (more than one cutaneous affection having been from
time to time classed under the same name), will justify our referring
the reader for the particular discussion of its etiology to another
part of this work. (See DISEASES OF THE CUTANEOUS SYSTEM.)

Haemophilia is clearly hereditary in certain families. Immermann
asserts it to be even a race-liability in the Jews. "Bleeders" upon
occasion of very small wounds of the skin, gums, etc. have been known
in several successive generations, including (Borner; Kehrer) women at
the time of parturition, who then are apt to have dangerous
hemorrhages.

Cancer presents as unmistakable examples of inheritance as any other
disease. Paget asserts this to be traceable in one case out of three;
Sibley, in one of nine; and Bryant, one of ten cases. De Morgan and
others have shown the same thing to be true of non-malignant morbid
growths. But, as Paget has remarked, when other local disease or
deformity is inherited, it usually involves in the offspring the same
tissue, often the same part of the body, as in the parent, but the
transmitted cancerous tendency may show itself anywhere: "Cancer of
the breast in the parent is marked as cancer of the lip in the
offspring. The cancer of the cheek in the parent becomes cancer of the
bone in the child. There is in these cases absolutely no relation at
all of place or texture."

Cataract is believed by good authorities to be promoted by hereditary
tendency. It is of the nature of a degeneration. Possibly, in a
greatly-prolonged decay of all the organs with age, all eyes tend to
become cataractous from structural alteration of the crystalline lens.
Under observation a quite different rate of degenerative change takes
place among the organs of the body in different individuals and
families. Thus, the lens becomes opaque in some at an age when the
hearing continues good and the muscles retain considerable vigor,
while in members of other families the eyes remain in a sound
condition at a time when other organs and powers have failed.
Congenital cataract appears to be altogether independent of any
proclivity transmitted from parents in the nature of an inheritance.

Affections of the nervous system very often show hereditary descent.
Neuralgia prevails strongly in certain families. Particularly, that
form of cephalalgia called sick headache is apt to appear, in the
periodical form, through several generations. Apoplexy and paralysis
are prone to occur at nearly the same time of life under the
transmission of like constitutions by parentage. Still more often this
has been observed of epilepsy and hysteria, and, most of all the
neuroses, in insanity. Monomania and melancholia have been in a great
number of instances traced to generative succession--sometimes,
especially suicidal monomania, through four or five generations.
Predisposition to intemperance, methomania, is also a terrible
inheritance in some families. Although the production of this malady
requires the provocative of indulgence in the use of alcohol for its
development, yet the facility with which this result occurs under the
same circumstances in different families is too marked to leave room
for doubt of its hereditary nature.

Less certainly, but with much probability, we may assign parental
endowment as one of the factors in the causation of organic disease of
{130} the heart, arteries, liver, and kidneys, as well as of angina
pectoris, asthma, croup, dyspepsia, and hemorrhoids.

Is a special proclivity to any of the group of enthetic febrile
diseases ever inherited? Dr. George B. Wood believed this to be the
case with enteric or typhoid fever. Few others have shared this
opinion, but it is not impossible that it has a basis of truth.

Reference has been made already to the difference between periodical
malarial fevers (intermittent, etc.) and yellow fever, in that an
attack of the latter does, and one of the former does not, protect the
individual, usually, from liability to the disease on exposure to its
cause. Does this protection extend to offspring of parents who have
been "acclimatized" to yellow fever? Facts on this point are not easy
to obtain. While, however, there appears to be no proof that a single
generation can ever suffice to outgrow (so to speak) liability to this
disease, it is well known that creoles in Louisiana and the West
Indies are less susceptible to it than recent white residents, and
that the negroes are much less so, as a race, than the whites.
Furthermore, negroes whose ancestors have long been domesticated in
our Southern States appear to re-acquire susceptibility to yellow
fever in a degree more nearly like that of white people than is
observed in natives of Western Africa imported within one or two
generations.

As to autumnal malarial fevers (remittent, intermittent), the black
race exhibits a sort of race-acclimatization, giving negroes, both in
Africa and in America, a much less degree of liability than is common
to all races of European descent.

How far any similar modification may occur in the course of
generations in regard to susceptibility to small-pox and allied
diseases remains at present a matter of speculation. Some authors
insist that there must be at least a kind of natural selection,
according to which a great epidemic of variola, destroying the lives
of many of those most predisposed to suffer from it, will leave the
remaining population less likely to be attacked by it. The endeavor
has even been made to explain away in this manner much of the
diminution of mortality from small-pox commonly credited to
vaccination. But the statistics of the ravages of variola in different
countries before and after the introduction of vaccination show that,
while we cannot deny that some alternation (of generations
respectively more and less susceptible) may occur, no such law can
compare in influence with that of vaccination in the protection of
individuals subjected to it. Indeed, the argument may be inverted;
thus: if in the days before Jenner small-pox itself weeded out the
persons most liable to it, or in some way prepared a partial family-
or race-protection, such a protection ought to be gradually conferred
upon a whole population through universal and persistent vaccination
carried on for several generations.

Is it possible for one hereditary constitution or diathesis to become,
in transmission, not only modified, but transmuted, into another? Some
of the older pathologists imagined this to be the case with syphilis,
to whose past influence upon parents and ancestors they traced the
origin of scrofula. But no sufficient ground for such a pathogeny can
be ascertained. All that appears to be left after scrutiny of the
facts is, that syphilis is a depressing and perverting agency, and so
may join with {131} other depressing causes in preparing the way for
the engendering of scrofulosis.

A few points still remain to be briefly mentioned in connection with
the hereditary conveyance of proclivity to disease. One or several
members of a family will often pass through life without any
manifestation of such transmission, while others, their brothers or
sisters, give marked evidence of it. Sometimes a whole generation may
be passed over, and yet the predisposition may be abundantly shown in
that next following. This is closely similar to atavism, as it is
called in zoology and general biology, according to which traits
occurring under admixture or variation of animal or vegetable stocks
may be absent in the immediate offspring of a couple, but reappear in
their next succeeding descendants, or even a still later reversion may
take place. Such instances are not rare, and they need to be
considered in the proper study of the influence of parentage,
intermarriage, etc. upon health and disease.

A practical question of much importance (belonging, however, rather to
sanitary than to medical science) is, how far confirmation or
modification of hereditary proclivities may occur through the effect
of the conditions of marriage upon offspring. Consanguineous marriages
have been, time out of mind, held to be very objectionable. The
question has been much discussed whether the ground of sanitary
objection is properly against such marriages as per se injurious to
offspring, or whether the bad effect consists merely in reduplicating
and intensifying family constitutional taints. It would not be in
place here to go into this controversy. My own conclusion is, that a
natural law of sexual polarity or affinity exists, according to which,
in all the higher organisms, reproduction is most normal and gives the
best results when a considerable genetic difference (within the limits
of species) exists between parents. While, however, this is probable,
but difficult to demonstrate, it appears to be certain that when a
father and mother both possess morbid constitutional predispositions
(say, to phthisis, insanity, or gout), their children will be at least
twice as likely to suffer from the same as if only one parent were so
endowed. Whether or not, then, the marriage of two perfectly healthy
first-cousins may be expected (as several statisticians aver to have
been shown) to be attended by defects of health in their progeny, the
union of such relations when their common progenitors were in marked
degree consumptive, or scrofulous, or liable to insanity, epilepsy,
etc., has attached to it so unfavorable a prognosis for offspring as
to be rightly forbidden. Moreover, so few families possess an
absolutely faultless health-record that the chances of increasing
existing morbid traits by intermarriages are quite sufficient to
justify the commonly held objection against them.

We must allude very briefly to the influence of conditions affecting
conception and gestation upon the health of offspring. Intemperance in
parents has, in many instances, been known to promote convulsions,
infantile or epileptic, and other cerebral or nervous disorders in
children, besides a general feebleness of constitution. Even
intoxication at the time of procreation has been asserted to mark a
similar difference between one child and another of the same parents.

All are familiar with the (no doubt often quite imaginary) accounts of
the effect on infants in utero of powerful sensory or mental
impressions upon the mother during gestation. Abortion has,
unquestionably, been {132} often produced by violent nervous shocks.
Without deciding the question whether "monsters" are ever developed in
correspondence with particular experiences of the mother, we may hold
it to be clear that all depressing and disturbing agencies may
interfere with the process of nutrition of the foetus, and thus
develop mental anomalies, and that constitutional impairments may thus
be greatly promoted.

All inherited predispositions, it is important to remember, are
aggravated, and each proclivity changed to actuality, by those
influences which in individuals tend to like effects upon health. Such
become exciting causes of various diseases. If these be constantly
avoided, and all the surroundings and the mode of life of the
individual be maintained in a manner most favorable to health, the
hereditary tendency may remain inert through a long lifetime. Every
physician must have seen this in scores of instances. The application
of the principle through special precepts belongs to personal hygiene.
But no physician can rightly ignore the study of this subject, or omit
the utilization of his acquaintance with it by preventive advice to
members of the families under his professional care.

Our last remark in connection with pre-natal causation must be upon
the effects of circumstances and modes of living on masses of men,
especially in large cities and populous countries. Something has been
said already of race-acclimatization by which there may be acquired a
lessened susceptibility to certain endemic fevers.[2] Almost a reverse
action is exhibited in the gradual lowering of vital energy under what
has been called the "great-town system." While those having all the
comforts of life and avoiding excesses may manifest but little of this
deterioration, it is very observable in that mass of men, women, and
children who become the subjects of medical charities. Closeness and
uncleanliness of living, with more or less exposure to dampness and
extremes either of heat or cold, with intemperance and syphilis, are
the main causes of this general constitutional impairment. So
important is it that it should never be forgotten, not only in our
estimate of the causation of diseases, but in our anticipation of
their results, and also in our adaptation of measures of treatment,
medical and surgical, to different classes of patients. All that it is
allowable here to suggest in this regard may be summed up (although
very imperfectly) in the word hospitalism.

[Footnote 2: It is important (but not before remarked in this article)
that cholera does not appear to allow of any such diminution of
liability to it among the natives of the country in which it is
endemic.]

Conditional causation has been, to a certain extent, included under
what has been above said, as it is the action, in part at least, of
surrounding conditions, that establishes a family- or race-proclivity
and inheritance. But we must say something more about the direct
action of conditions upon individuals.

Man, although organized with great delicacy of structure, is capable,
by the use of his intelligence, of adapting himself to a wider variety
of external conditions than any other animal. He is the only truly
cosmopolitan being on the earth. From the remote Arctic regions to the
hottest tropical climates there are tribes whose ancestors have dwelt
for centuries in the same localities. Not that no unfavorable
influence attends these extremes. The Esquimaux are stunted, the
Southern Hindoo and {133} Central African are enfeebled and
degenerate, partly from climate. But with man's numerous protective
devices, great cold and great heat only exceptionally affect
individual health. Freezing to death follows unusual exposures; the
loss of an extremity by sphacelus from congelation is more often met
with; heat-stroke also is tolerably frequent; and the influence of
heat in producing cholera infantum in some large cities is very
important; but much the most common kind of conditional morbid
causation is produced either by sudden changes of temperature or by
diversity of exposure of different parts of the body. These are the
two usual modes of "taking cold." When dampness accompanies a
relatively low temperature, such an effect is much more apt to follow
than in a cold dry atmosphere.

Actual cold-stroke, the analogue of heat-stroke, may sometimes happen.
I once saw such a case in a previously healthy boy twelve years of
age, who, after standing for an hour in his night-shirt on a cold
winter night, became almost immediately ill, fell into a comatose
state, and died in about thirty-six hours.

A simple rationale may be discerned for the phenomena of catching
cold. When, for example, a draught of air blows for a time upon the
back of a person at rest (especially one who has just before used
active exertion), the local refrigerant impression induces
constriction of the superficial blood-vessels. Hence follow two
effects: one, the repulsion of blood in undue amount toward interior
organs; the other, diminution, perhaps arrest, of excretion from the
skin of the exposed portion of the body, and consequent retention of
some effete material, promoting esotoxaemia.[3] If, then, there be in
the body any weak organ--that is, one whose circulation is partially
impeded or whose nutritive and functional activity is low--it suffers
first and most from the impulsion of blood from the surface.
Congestion, irritation, and inflammation may follow, and we have an
attack of pneumonia, pleurisy, bronchitis, or some phlegmasia.

[Footnote 3: That is, blood-poisoning, originating within the body
itself; exotoxaemia being that which is enthetic--_i.e._ resulting
from a poison derived from without.]

Excessive heat with dryness, as under the blasts of the Simoon or the
Harmattan of Arabia or Northern Africa (apart from insolation,
sunstroke, or heat-stroke), may sometimes parch the body even to a
fatal degree. Much more common is the combination of high temperature
with humidity. This has a relaxing effect, promoting indolence of
temperament and predisposing to disorders of a catarrhal nature,
especially of the digestive organs, such as were called fluxes by the
older writers.

Cold climates are well known to present the greatest number of cases
of acute and chronic affections of organs of the respiratory system;
warm and hot climates, those of the stomach, liver, spleen, and
bowels. But we must recollect what various complications belong to
climate. Two important factors, especially, must be kept in view in
comparing the causation of diseases in colder and warmer
countries--namely, the difference in the articles of food partaken of
in each, and the external sources of enthetic disorders; _e.g._
endemic and epidemic fevers, etc.

With humidity must be considered variations in atmospheric pressure.
Physicists have long known that while watery vapor, by itself, is
heavier than air which is perfectly dry, moist air is lighter than air
containing {134} little or no moisture. Hence the barometer falls as
the quantity of atmospheric moisture approaches saturation. Other
causes, however, also affect barometric pressure. With the same degree
of humidity, cold air is denser and heavier than warm air, and by its
contraction lowering the "column" of atmosphere--the temperature of
which is reduced--a flow toward the upper part of the column increases
the actual mass of air pressing upon a particular place. Elevation of
a locality above the general level of the earth reduces atmospheric
pressure, sensibly as well as measurably. So "the difficult air of the
iced mountain-top" has become proverbial.

These variations are familiar, though all their effects upon human
health have been by no means, as yet, fully studied. Most difficult to
determine and analyze are the influences of changes of pressure,
chiefly hygrometric, upon the course of diseases and upon the result
of severe surgical operations. Among the few important series of
observations bearing on this topic have been those of Dr. S. Weir
Mitchell on neuralgia,[4] and Dr. Addinell Hewson on the prognosis of
major operations,[5] in connection with the state of the weather. The
former ascertained a marked relation between the approach of a wave of
low barometric pressure and attacks of irregularly periodic neuralgia;
the latter proved, by the statistics of the Pennsylvania Hospital for
a number of years, that the most favorable time for amputations or
other capital operations is when the barometer is high, or at least on
the ascent.

[Footnote 4: _American Journal of Medical Sciences_, April, 1877, p.
305.]

[Footnote 5: _Pennsylvania Hospital Reports_, 1868.]

Electrical atmospheric states and vicissitudes have, quite probably, a
practical consequence beyond what is usually ascribed to them in
connection with health and disease. But their effects are so difficult
to disentangle from those of other meteorological causes that we must
be content at present without attempting their exact specification.
The same observation may be made with reference to ozone.

Elevation of site has importance, not only in regard to climatic
hygiene, but also to its therapeutic use, particularly in the
treatment of phthisis, goitre, and some affections of the nervous
system. But in our brief and general survey of Etiology this topic
must be left without discussion, since no disorder appears to be
traceable to elevation alone, beyond the temporary prostration on
exertion, with hemorrhages from the nose, lungs, etc., often produced
in those who climb to great mountain-heights or ascend rapidly in
balloons. It has been shown by ample experience that considerable
populations may live in ordinary health through long periods at
altitudes more than 10,000 feet above the level of the ocean.

Depression below the surface of the earth has never become a part of
human experience beyond the limit of a few hundred feet. Miners living
underground in a few places in Europe have been found to exhibit
comparatively feeble health, but the privation of sunlight, the
confined atmosphere, and the dampness of such unnatural abodes will
suffice to account for these effects.

Under functional causation of disease we may include all excessive,
deficient, or abnormal exercise of any of the organs of the body. To
simple excess may be ascribed the scrivener's or bank-officer's
paralysis of the muscles of the hand used in continuous writing; brain
{135} exhaustion from mental labor or anxiety, unrelieved by
sufficient sleep; and sexual impotence, temporary or lasting (or
sometimes even general paralysis), from inordinate sexual or sensual
indulgence.

Deficiency of functional exercise is observed to produce disability,
as when the muscles of a limb, for instance, are for a long time
restrained from use. Surgeons meet with this inconvenience (unless
assiduously guarded against) when a fractured limb is kept long at
rest in a fixed position. Atrophy of the mammae in single women of
retired lives is common; atrophy of the testicles in unmarried men
much less so. These changes, however, are physiological, not
pathological; upon alteration of conditions--_e.g._ marriage--the
atrophy will disappear altogether.

Abnormal functional action as a cause of morbid results is seen when
the eyes are injured by reading, writing, or doing any delicate work
in a bad light; for instance, late twilight. Also, in a secondary or
accessory manner, when a near-sighted person, having the action of the
muscles of convergence in excess of his accommodation, or a
long-sighted (hyperopic) person, whose accommodation is in excess of
convergence, suffers from asthenopia, perhaps with headache, distress,
nausea, etc. Another example of abnormal functional exercise and its
effects is that of self-abuse, where the unnatural mechanical
imitation of the physiological act of sexual coition induces
disturbances of the nervous and circulatory systems, besides debility
from excess.

Ingestive causation is a sufficiently fit designation for all errors
of diet, as well as misuse of medicines, and poisoning. Starvation or
inanition belongs to the same category by negation. Gluttony and
intemperance are major members in the ingestive series, while haste in
taking food, without mastication, and the use of heavy bread, unripe
fruit, and other indigestible articles, account for many cases of
dyspepsia and some of colic, cholera morbus, diarrhoea, etc. With
young children, especially, no more frequently acting cause of
disorder exists than dietetic mismanagement, most of all during the
period of dentition, and earlier, when, from absence or insufficiency
of mother's milk, they have to be artificially fed. Then the supply of
good fresh cow's, goat's, or ass's milk may carry them well through
infancy, while a regimen of arrowroot or gum-arabic and water, or
stale, half sour milk, may either starve or sicken them to death. On
the subject of poisons and of misuse of medicines we have no occasion
here to make special remark. Only it may be mentioned that the
possibility of either is always to be remembered by the physician in
making up his mind in regard to the origin of symptoms observed.

Enthetic causation is a large subject, including all origination of
disease by the introduction of morbid materials from without the
body.[6] Medical opinion has generally accepted, and facts fully
sustain, the recognition of three groups of enthetic disorders, viz.:
those which are personally contagious; such as are locally epidemic;
and epidemic diseases. Of the first group it will suffice to mention,
as an example, syphilis; of the second, intermittent fever; of the
third, influenza.

[Footnote 6: Simon has proposed the term exopathic to indicate the
origin of such maladies; autopathic disorders being those which
originate within the body itself.]

Were all maladies whose causation is evidently of external origin
capable of the same clear discrimination as these, we should have no
difficulty with the present topic. But, in fact, no subject connected
with {136} the history of disease has become surrounded by more
intricate controversy. Many times the same facts are, or appear to be,
explicable in two or three different ways. What some hold to be proofs
of contagion from person to person, others are ready to account for by
the subjection of a number of persons or of a whole community to
either a common local or a widespread migrating (epidemic) influence.
It is sometimes impossible, in the nature of things, to obtain an
absolute demonstration of the truth of one or another of these
theories without such experiments upon human beings as are
impracticable.

While endeavoring to ascertain the limits of our present knowledge
upon these questions, let us first notice what are the most positive
facts concerning them, some of which are common to the whole group or
class of what have been, since Liebig, often called zymotic,[7] but
latterly more often enthetic, diseases.

[Footnote 7: The term zymotic has, with many authors, fallen into
disrepute, chiefly because Liebig's hypothesis concerning the
chemico-physical action of ferments, as well as of contagia, has lost
ground in comparison with the vital or disease-germ theory. Yet the
analogy between fermentation, putrefaction, and the action of a virus
on an animal organism persists; whatever may be the theory of their
explanation, something appears to be common or similar in all these
processes.]

These diseases may be enumerated as follows:

1. _Only produced by contact or inoculation_.

  Primary Syphilis,
  Gonorrhoea,
  Vaccinia,
  Hydrophobia.

2. _Contagious also by atmospheric transmission through short
distances_.

  Variola,
  Varioloid,
  Varicella,
  Measles,
  Diphtheria,
  Scarlatina,
  Rotheln,
  Mumps,
  Whooping Cough,
  Typhus,
  Relapsing Fever.

3. _Endemic, occasionally epidemic_.

  Malarial Fevers (Intermittent, Remittent, and Pernicious Fever),
  Dengue,
  Yellow Fever.

4. _Other zymotic or enthetic diseases_.

  Influenza,
  Cerebro-spinal Fever,
  Erysipelas,
  Puerperal Fever,
  Tropical Dysentery,
  Typhoid Fever,
  Cholera,
  Plague.

As all observers are agreed in regard to the personal transmission of
the first named of these series (variola, etc.), we need to give
attention here only to the other groups; except merely to say that the
easily demonstrable existence of a morbid material (virus) in the
instances of primary syphilis, gonorrhoea, variola, and vaccinia
presents a very cogent analogical argument for the presumption that
all clearly contagious (even {137} though non-eruptive) maladies, such
as mumps and whooping cough, must also have a morbid material as their
essential cause; and also in favor of the supposition that a morbid
material may probably be the "causa sine qua non" of each of the other
maladies which are known to be endemic or epidemic. A few theorists
only have argued in favor of any other view than this. Sir James
Murray and Dr. Craig of Scotland, and Dr. S. Littell of Philadelphia,
have sustained an electrical hypothesis, and Oldham and others have
advocated one connected with changes of bodily temperature, or ozone,
etc., for the origination of certain endemic and epidemic diseases.
But all the facts point toward the existence of material causes,
specific for each of these disorders, and many observations and much
ingenuity of reasoning have been brought to bear upon the question as
to their intimate nature.

Are these materiae morborum merely inorganic elements or compounds
entering human bodies and acting there as chemical poisons? Against
such a supposition we have, as almost decisive objections, not only
the absence, under the most searching analysis, of any chemical
peculiarity in the air of malarious or otherwise infected regions, but
also the clinging of many endemic and epidemic causes (as known by
their effects) to particular localities, notwithstanding the
recognized law of the diffusion of gases which must antagonize such
concentration. Therefore, we may rule out, as highly improbable at
least, the hypothesis of the inorganic gaseous nature of malaria, as
well as of the essential causes of yellow fever, cholera, plague, and
the other analogous diseases.

By the once general use of the term zymotic, there is suggested a line
of thought which has been quite prevalent since the prominence of
Liebig's teachings in chemical physiology, until recently. That great
chemist did not imagine that a true zymosis or fermentation occurs
under the action of a virus upon the human economy. His thought was
more clearly expressed, in the phraseology of the late Dr. Snow of
London, as the theory of continuous molecular change. Its most
striking physical instance or analogue is the extension of flame from
a burning body to combustible matter within its reach. Sugar formation
from starch by diastase, and the change of albumen into peptone by
pepsin, are familiar examples, in organic materials, of the
propagation of molecular movement in special directions and with
characteristic results.[8] It does not seem to be more than a short
step from these to the processes which we study in fermentation,
putrefaction, septicaemia, and the multiplication of small-pox
contagion, from the smallest inoculation, in the human body.[9]

[Footnote 8: In anticipation of the argument concerning the necessity
of the action of minute living organisms to produce fermentation,
putrefaction, and specific diseases, emphasis may be here laid upon
the fact that the above named changes, and many others like them, are
produced, in the absence of such organisms, by chemical agents formed
in the body, or even (as when sulphuric acid changes starch to sugar)
by inorganic substances. Pasteur considers that the yeast-cell
secretes a sort of diastase which changes starch or cane-sugar into
glucose, on which the cell then lives, decomposing the glucose into
alcohol, carbonic acid, etc. Koch and others now assert that a
bacillus produces the souring of milk, and another the butyric acid
fermentation.]

[Footnote 9: The assertion of some advocates of the "germ theory of
disease," that only living organisms reproduce their kind, loses
weight as an argument in view of the natural history of small-pox and
analogous diseases; unless it be proved that every particle of
contagious matter is (at one time at least) a living organism.]

But here comes in a new hypothetical factor, introduced by the aid of
{138} the microscope, although anticipated conjecturally before actual
discoveries in this field were made certain. So prominent is this
subject in the discussions of the present time, under the expression
"the germ theory of disease," that we are justified in giving
attention to it here somewhat at length.

Stahl proposed a purely chemical theory of fermentation early in the
seventeenth century. Not much later Hauptmann suggested the probable
causation of epidemic diseases by minute living organisms.
Linnaeus[10] revived this hypothesis in the eighteenth century. These
two topics of inquiry, with the intermediate one of putrefaction, then
received much attention, at first apart, but afterward with
recognition of their analogies. When Fabroni, Cagniard de la Tour,
Schwann, and Kutzing had, with the aid of the microscope, made
familiar the life-history of the yeast-fungus[11] (Saccharomyces
cerevisiae), more close consideration still was given to these
remarkable changes in organic materials and forms, dead and living.

[Footnote 10: Linnaeus accepted the asserted observation by Rolander
of acari in the stools in dysentery. The great naturalist deviated
somewhat here from his usual carefulness and accuracy, as that
observation was not afterward verified.]

[Footnote 11: Leuwenhoek, however, had observed and described it in
1680.]

Starting from the physical basis of inorganic chemistry, Liebig
followed the series up from the so-called catalytic[12] action by
which the presence of a substance, itself apparently unchanged,
induces reaction between two or more other bodies, to those which
occur within plants and animals, as examples of vital chemistry. Such
is the influence of diastase or invertin, which in the seeds of plants
brings on the conversion of starch into sugar and of cane-sugar into
glucose and levulose. Such is the agency of ptyalin in the saliva, of
pepsin in the gastric juice, and of pancreatin or trypsin in the
secretion of the pancreas, in the processes of digestion. From these
it appears to be an easy transition to those changes which occur in
organic matter no longer living, as in the fermentation of vegetable
juices and the putrefaction of animal tissues.[13] Liebig endeavored
to explain these also in the same manner as the chemico-vital
processes; and he then went farther to apply the same generalization
to the propagation of disease, by what is called virus, in the
instances of contagious, endemic, and epidemic maladies.

[Footnote 12: The idea expressed by this term was especially favored
by Berzelius and Mitscherlich.]

[Footnote 13: It is noticeable, however, although generally forgotten,
that the one set of changes and assimilations (namely, those of
digestion) are formative actions of life, and the others destructive,
in the direction of, or subsequent to, death.]

But, meanwhile, observation and speculation gave almost equal
prominence to the importance of minute living organisms in the
apparent instigation of all these evidently analogous changes of
fermentation, putrefaction, suppuration, septicaemia (Piorry, 1835),
infection, and contagion.

Upon this side the leading investigator for many years has been
Pasteur. As long ago, however, as 1813 Astier, and in 1840 Henle of
Berlin, and near the same time Sir Henry Holland of London and Dr. J.
K. Mitchell of Philadelphia, gave expression to opinions of a similar
kind, based upon many important facts before very much overlooked. By
exact experimentation, moreover, Schwann, Helmholtz, Schroeder, and
Dusch ascertained that the agent or agents causative of fermentation
and putrefaction can be detained by heated tubes, by animal membranes,
{139} and by cotton wool, anticipating the later observations of
Pasteur,[14] Tyndall, Chauveau, and others to the same or similar
effect. These results of experiments are commonly understood to prove
the particulate character of the agents so studied. What may be called
an era in the practical application of etiological inquiry dates from
the introduction by Lister (about 1860) of the principles of
antiseptic surgery, based upon the theory that disease-germs, derived
from the atmosphere or other external sources, are the essential
causes of suppuration, septicaemia, pyaemia, gangrene, etc. following
injuries or operations.

[Footnote 14: Pasteur's experiments with long-drawn bent tubes had
especial significance.]

So far from this inquiry being yet terminated, while experiments and
observations have become more and more numerous and elaborate,
opinions continue to differ; and we must yet await the time when, by
successively excluding, one after another, all the sources of error, a
truly scientific conclusion may be obtained.

Roughly speaking, it may be said that parties in the debate are
chiefly ranged upon two sides--those who favor the probability that
only chemical, not vital, action is to be traced in fermentation,
putrefaction, suppuration, infection, and contagion; and those who
regard minute organisms, discovered or undiscovered, as causative of,
and indispensable to, all these processes.

Without intention of injustice to other able investigators, the
principal names so far associated with the former of these views may
be thus mentioned: Panum (1856), Robin, Bergmann, Liebig, Colin,
Lebert, Vulpian, Onimus, B. W. Richardson,[15] Beale,[16] Senator,
Rosenberger, Hiller, Naegeli, Schottelius, Harley, Jacobi, Curtis, and
Satterthwaite. Of those maintaining, in some form and with more or
less positiveness, the disease-germ theory, the most conspicuous,
especially as observers, have been Tuchs (1848), Royer (1850),
Davaine, Branell, Pollender, Pasteur, Tyndall, Lister, Mayrhofer,
Ortel, Letzerich, Nassiloff, Hueter, Toussaint, Hansen, Salisbury,
Klob, Hallier, Basch, Virchow, Neisser, Eberth, Tommasi Crudeli,
Klebs, Talamon, Schuller, Tappeiner, Cohnheim, Koch, Baumgarten,
Buchner, Aufrecht, Birch-Hirschfeld, Greenfield, and Ogston. Besides
these the elaborate studies of microphytes by Cohn, and those of Coze
and Feltz, Waldeyer, Recklinghausen, and others upon septic poisoning,
have been of acknowledged importance; and the experimental labors of
Burdon Sanderson in England, and Sternberg,[17] H. C. Wood, and Formad
in the United States (under the auspices of the National Board of
Health), possess great value. But the scientific caution of these last
inquirers, like that of Magnin, has prevented them from formulating,
as yet, positive and final opinions upon the subject. It is not saying
too much to assert nearly the same of {140} several of those mentioned
above, as inclining to one or the other side of the controversy.[18]

[Footnote 15: Dr. Richardson has long contended for the doctrine first
proposed by Panum, that a peculiar chemical agent, (called by Bergmann
_sepsin_) is the cause of blood-poisoning from virulent absorption or
inoculation. Latterly, attention has been called by Selmi and other
observers to the existence of complex compounds called _ptomaines_ in
decomposing animal substances--_e.g._ the human body after
death--these having considerable resemblance in their toxic action to
the poisonous vegetable alkaloids.]

[Footnote 16: Opposed at least to the ordinary form of the germ theory
of disease.]

[Footnote 17: Sternberg's observations and experiments (following
those of Pasteur) with the inoculation of animals with saliva, proving
that even when taken from perfectly healthy men this may be fatally
poisonous to animals, possess remarkable interest. They do not seem,
however, to be decisive either way in regard to the germ theory of
infection.]

[Footnote 18: Billroth and Cohnheim are among those who have changed
their opinions on this subject after prolonged investigation.]

It would appear, then, that the data for a final conclusion have not
yet been made certain. Several hypotheses are conceivable, and
capable, each, of plausible support:

1. The purely chemical theory of Liebig, Gerhardt, Bergmann, Snow of
London, and B. W. Richardson.

2. The bioplastic hypothesis of Beale, according to which germinal
matter may be detached from a living body and planted, while yet
retaining vitality, upon another, and there may undergo changes more
or less morbid, and destructive of the body by which it has been
received. This theory of migrating or transplanted bioplasts has
received very little support besides that of its distinguished author.

3. That the minute organisms discovered so constantly upon diseased
parts of plants and animals (_e.g._ ergot of rye, _Peronospora
infestans_ of potato-rot, _Botrytis Bassiana_ of silk-worm muscardine,
_Panhistophyton_ of silk-worm pebrine, _Empusa muscae_ of the fly,
_Achorion_, _Tricophyton_, _Oidium_, and _Leptothrix_ of human
affections of the skin and mucous membranes) are incidental or
accidental only[19]--acting, as R. Owen observes, {141} most commonly
as natural scavengers in the consumption of effete organic material;
but that they may become noxious under two sorts of
circumstances--viz. when their numbers are enormously increased, as is
known to be the case with trichinae in the human body, and also when
they are brought in considerable number into contact with bodies
already diseased, or at least suffering under depression of vital
energy.

[Footnote 19: This possibility has not been as yet altogether ruled
out in regard to Koch's _Bacillus tuberculosis_; concerning which
active discussion has been going on during the past year or two
(1882-83). A very large number of observers confirm the statement that
the bacilli are found in most specimens of tubercle. Several, also,
have repeated with success Koch's inoculation experiments, in which
tubercle appeared to be propagated by carefully isolated bacilli. But
many facts still stand in the way of the conclusion that the bacillus
is the causa sine qua non of tuberculosis. First, examples of the
production of phthisis by apparent contagion or infection are few.
Although Dr. C. T. Williams found bacilli in the air of the wards of
the Hospital for Consumptives at Brompton, yet of the experience of
that hospital Dr. Vincent Edwards, for seventeen years its resident
medical officer, reports as follows: "Of fifty-nine resident medical
assistants who lived in the hospital an average of six months each,
only two are dead, and these not from phthisis. Three of the living
are said to have phthisis. The chaplain and the matron had each lived
there for over sixteen years. Very many nurses had been in residence
for periods varying from months to several years. The head-nurses,"
says the writer, "sleep each in a room containing fifty patients. Two
head-nurses only are known to have died--one from apoplexy; the other
head-nurse was here seven months, was unhappily married, and some time
afterward died of phthisis. Of the nurses now in residence, one has
been here twenty-four years, two twelve years, one eight years, one
seven years, one six and a half years, and one five years. No
under-nurse, as far as I am aware, has died of phthisis. All the
physicians who have attended the in-and-out patients during the past
seventeen years are living, except two, who did not die from
phthisis."

Against the inoculation and inhalation experiments of Villemin,
Tappeiner, Koch, Wilson Fox, and others, by which the specific
character of tubercle has been said to be proved, must be placed those
of Sanderson, Foulis, Papillon, Lebert, Waldenburg, Schottelius, Wood
and Formad, Robinson, and others, by which tubercles have been induced
by the injection, inoculation, or inhalation of various non-tubercular
materials. In answer to the argument from these, it is asserted by
Koch and his supporters that "there is no anatomical or morphological
characteristic of tubercle," its only sufficient test being its
inoculability. This is almost begging the question; at all events, it
leaves it, for the present, unsettled. Moreover, tubercular deposits
do not always contain bacilli, as has been shown by Spina, Sternberg,
Formad, Prudden (_N.Y. Medical Record_, April 14 and June 16, 1883).
The last named made, in one well marked case, six hundred and
ninety-five sections from ninety-nine tubercles in different portions
of a tuberculous pleura, all of Koch's precautions being observed in
the examination. Belfield (_Lectures on Micro-Organisms and Disease_)
admits the possibility that tuberculosis may be produced by either of
several causes. It has, at least, not yet been demonstrated that the
tubercular tissue is more than a nidus or favorable "culture-ground"
for the bacilli, or that, in the presence of a constitutional
predisposition, they may not merely promote a more rapid destruction
of the invaded organs or tissues.]

4. That such organisms are the essential and direct causes of enthetic
maladies by invading the human and other living bodies as parasites,
consuming and disorganizing their tissues, blood corpuscles,[20] etc.
Pasteur considers the abstraction of oxygen an important part of their
action.

[Footnote 20: Against this view stands especially the objection that,
as Cohn, Burdon Sanderson, and others have fully shown, bacteria and
other Schizomycetae obtain their nitrogen, not from organized tissues,
but from ammonia, and their carbon and hydrogen from the results of
decomposition in organic tissues. (See B. Sanderson, in _Brit. Med.
Journal_, Jan. 16, 1875.) Pasteur has regarded the relation of these
organisms to oxygen as important; some of them requiring it for their
existence (aerobic), and others not (anaerobic). He has defined
fermentation as "life without free oxygen."]

5. That these microbes, microphytes, or mycrozymes act not as
parasites, but as poison-producers, secreting a sort of ferment which
is the specific morbid material (Virchow); or, when multiplying in
excess of their food-material, they may die, and their dead bodies,
like other decaying organic matter, may become poisonous. This
possibility, although not distinctly suggested (so far as I know)
hitherto, appears to me to be not unworthy of consideration. That the
numbers of micro-organisms present have some important relation to
morbid conditions has long since been inferred from familiar facts.

6. That they are not generators, but carriers, of disease-producing
poisons; their vitality giving to the latter a continuance of
existence and capacity of accumulation and transportation not
otherwise possible.

Briefly, the following is a summary of the most generally accepted
classification of those microscopic organisms[21] whose role in the
causation of diseases is now under discussion; chiefly following Cohn
and Klebs:

_Orders_: Hyphomycetae, Algae, Schizomycetae.

Hyphomycetae, _genera_: Achorion, Tricophyton, Oidium.

Algae, _genera_: Sarcina, Leptothrix.

Schizomycetae, or Bacteria, _genera_: Micrococcus, Rod-bacterium,
Bacillus, Spirillum.[22]

[Footnote 21: For further details concerning these the reader is
referred to the works of Magnin, Belfield, and Gradle on _The
Bacteria_, and on the _Germ Theory of Disease_.]

[Footnote 22: Cohn also separates vibrio and spirochaete as genera
distinct from spirillum. They may, however, be regarded rather as
species of that genus. Some recent authors included bacterium and
bacillus under one genus, bacillus; against which simplification there
seems to be no valid objection.]

Micrococci (Sphaerobacteria of Cohn) are asserted (under certain
conditions) by Letzerich, Wood, and Formad[23] to be causative of
diphtheria; Ogston has found them in ordinary pus; Rindfleisch,
Recklinghausen, Waldeyer, Birch-Hirschfeld, and others report them to
be always present in the abscesses of pyaemia; Buhl, Waldeyer, and
Wagner state their occurrence in intestinal mycosis; Eberth, Koster,
Maier, Burkhardt, and Osler, in ulcerative endocarditis; Orth,
Lukomsky, Fehleisen, and Loeffler, in erysipelas; Coats and Stephen in
pyelo-nephritis; Friedlander, in pneumonia; Eklund (_Plax scindens_)
in scarlet fever; Keating[24] and {142} Le Bel, in measles; Leyden and
Gaudier, in cerebro-spinal meningitis; Carmona del Valle, in yellow
fever; Prior, in dysentery; Gaffky, Leistikow, Bokai, and Bockhardt,
in gonorrhoea;[25] besides other similar observations by numerous
writers.

[Footnote 23: _Bulletin of National Board of Health_, Supplement No.
17, Jan. 21, 1882.]

[Footnote 24: _The Medical News_, Philadelphia, July 29, 1882.]

[Footnote 25: Sternberg's careful experimentation seems to show the
identity of Neisser's gonococcus with the Micrococcus ureae, commonly
found in decomposing urine.]

Bacterium termo is regarded by leading authorities as the special
ferment or causative agent of putrefaction[26] (Billroth, Cohn).

[Footnote 26: Others have referred putrefaction to vibriones, less
precisely described.]

Bacillus includes, hypothetically at least, several species; as
Bacillus subtilis, the innocent hay-fungus; Bacillus anthracis, the
microbe of malignant pustule (anthrax, milzbrand, charbon) and the
splenic fever of sheep; Bacillus typhosus (Klebs, Eberth, Meyer) of
typhoid fever; Bacillus leprae (Hansen, Neisser, Cornil, Koebner) of
leprosy;[27] Bacillus malariae, reported as having been
demonstrated[28] by Klebs and Tommasi Crudeli, Marchand, Ceri, and
Ziehl; Bacillus tuberculosis (Koch, Baumgarten, 1882); the bacillus of
malignant oedema (Gaffky, Brieger, Ehrlich); that of syphilis
(Aufrecht, Birch-Hirschfeld,[29] Morrison); of glanders (Loeffler,
Schuetz, Israel, Bouchard); of pertussis (Burger); besides the
Actinomycosis of Israel, Ponfick,[30] Bollinger, and others. Koch has
very recently (1883) been reported to have discovered in Egypt the
bacillus of cholera.

[Footnote 27: Dr. H. D. Schmidt of New Orleans, an experienced
pathologist, reported (_Chicago Medical Journal and Examiner_, April,
1882) that critical examination of numerous specimens of tissues from
three cases of leprosy under his care failed to verify the existence
of bacilli as characteristic of that disease.]

[Footnote 28: Not certainly, however, as shown by Sternberg (_Bulletin
of Nat. Board of Health_, Supplement No. 14, July 23, 1881). Dr.
Salisbury of Ohio in 1866 made a series of observations, on the basis
of which he asserted the discovery of a genus of malarial microphytes,
which he referred to the family of _Palmellae_.

The oval and spherical organisms described by Richard and Laveran as
found in the blood of malarial patients resembled micrococci rather
than bacilli.]

[Footnote 29: More recently described by him as micrococci.]

[Footnote 30: _Die Actinomykose_, 1881.]

[Illustration: FIG. 1. Micrococci: _a_, zoogloea form; _b_,
micrococcus from urine, in rosary chain; _c_, rosary chain from
spoiled solution of sugar of milk (Cohn).]

[Illustration: FIG. 2. Bacteria: _a_, zoogloea of _Bacterium termo_;
_b_, pellicle of bacteria from surface of beer; _c_, _Bacterium
lineola_, free; _d_, zoogloea form of _B. lineola_.]

[Illustration: FIG. 3. _Bacillus malariae_ of Klebs and Tommasi
Crudeli.]

[Illustration: FIG. 4. Bacteria from gelatin solution, inoculated from
swamp-mud, X 1500 (Sternberg).]

[Illustration: FIG. 5. Vibrios in gelatin culture-fluid, X 1000
(Sternberg).]

[Illustration: FIG. 6. Protococcus from slides exposed over swamp-mud,
X 400 (Sternberg).]

[Illustration: FIG. 7. Bacilli from swamp-mud, X 1000 (Sternberg).]

[Illustration: FIG. 8. Bacilli from septicaemic rabbit, X 1000
(Sternberg).]

[Illustration: FIG. 9. Bacilli from human saliva, X 1000 (Sternberg).]

[Illustration: FIG. 10. _Bacillus anthracis_ (Sternberg).]

[Illustration: FIG. 11. _Bacillus tuberculosis_, within and outside of
pus-corpuscles (Sternberg).]

Spirillum (Spirochaeta of Ehrenberg) has its best ascertained example
in the minute forms first observed by Obermeier, and afterward by many
other observers, in the blood of patients suffering with relapsing
fever. They have been found present in the blood only during the
febrile paroxysm, disappearing in the intermission and through
convalescence.

Hastening to close our consideration of this subject, we may note,
without much argument, a few of the points of difficulty needing yet
to be more fully illuminated by {143} careful observation before any
form of the germ theory can take its place as an established doctrine
in etiology:

1. The absence of the characters belonging to definite organisms[31]
in the easily-studied virus of small-pox and vaccinia stands, a
priori, against the probability of such organisms being essential to
the causation of other enthetic diseases.

[Footnote 31: The particulate character of variolous and vaccine virus
has been already alluded to, as asserted to have been shown by
Chauveau and others. Yet it is not absolutely demonstrated that
filtration may not produce an important chemical alteration in some
kinds of highly unstable organic material subjected to it. Cohn
figures a Micrococcus vacciniae in his article on Bacteria
(_Microscopical Journal_, vol. xiii., N. S., pl. v., Fig. 2). Beale
denies (_Microscope in Medicine_, 4th ed.) the existence of any
organisms in vaccine virus. Lugginbuhl, Weigert, Klebs, Pohl-Pincus,
and others have asserted their existence, but, especially in the
absence of any successful culture experiments, it does not seem to be
proved.]

2. Analogy in nature, showing the commonly beneficial action of
nutritive processes in re-appropriating the products of organic decay
on a large or on a small scale, makes the scavenger theory of the
general function of minute cryptogamic organisms more probable, per
se, than that which holds many of them to be destructive parasites or
poison-producers in the bodies which they may inhabit. Few well known
parasites are capable of causing death in higher animals or in man.

3. These microbes are among the minutest objects which can be studied
under the microscope. Bacteria average about 1/9000 of an inch in
their longest diameter; micrococci and spores (Dauersporen, Billroth)
are yet smaller. Much care, therefore, as well as skill, must be
exercised in making observations upon them.[32] Huxley asserted a few
{144} years ago that a distinguished English pathologist had mistaken
for movements of minute living organisms the "Brownian movements" seen
in the particles of many not living substances under a high magnifying
power. One observer, at least,[33] considers that the forms designated
as bacteria and micrococci, etc. are either forms of coagulated fibrin
or granules from morbidly-altered blood-corpuscles (zoogloea of
Billroth, Wood, Formad, and others). Koch denies the validity of the
observation of organisms in tubercle by Klebs and Schuller, while
insisting upon his own demonstration of a bacillus tuberculosis.
Authorities must, by mutual confirmation or correction, remove these
obscurities.

[Footnote 32: A very interesting discovery was made by Tyndall, to the
effect that while one boiling of a liquid would sterilize it for the
time by destroying all the bacteria present, their spores might still
retain vitality and be afterward developed. By repeated exposure to a
boiling temperature, taking these spores in their developing stage,
they were destroyed, and complete sterilization was effected.]

[Footnote 33: R. Gregg, _N.Y. Med. Record_, Feb. 11, 1882. Sternberg,
however, has replied to him (_N.Y. Med. Record_, April 8, 1882, p.
368). The latter admits a doubt as to whether the granules seen within
the leucocytes by Wood and Formad in diphtheritic material, and
believed by them to be micrococci, are such, or are merely granules
formed or set free by disorganization of protoplasm within the
leucocytes. This uncertainty well illustrates the difficulty of these
investigations.

A chemical test much relied upon is, that bacteria resist the action
of acids and alkalies, which destroy granular material of animal
origin; also, that all these organisms are deeply stained by aniline
dyes and by haematoxylin. The most decisive test, however, is
cultivation in a liquid sterilized by heat. Koch prefers a process of
dry culture for the bacillus of tubercle.

Gradle (_Lectures on the Germ Theory of Disease_, Chicago, 1883, p.
28) says that the absolute criterion of the life of bacteria is their
power of multiplication.]

4. Bacteria and micrococci have been abundantly discovered (Kolaczck;
J. G. Richardson) in healthy bodies upon the various mucous membranes
and in the blood. The correctness of such observations has been
denied, but, so far at least as the mucous membranes are concerned, it
has been well established by Nothnagel, Sternberg, and others.
Bacteria have sometimes been found in countless numbers in fecal
discharges.

5. Bacteria become most numerous in materials of a septic or
infectious character after their period of toxic intensity has passed
by.

6. Suppuration can be produced (Uskoff, Orthmann) without the presence
of minute organisms of any kind. Bacteria have been found {145} under
Lister's antiseptic dressings without suppuration following. Paul Bert
destroyed all the microbes in a septic liquid, and yet found it to
retain its poisonous quality. Rosenberger (1881) has made similar
observations.

Panum, Coze, and Seltz, Bergmann and Schmiedeberg, Hiller, Vulpian,
Rosenberger, Clementi, Thin, and Dreyer have, by various elaborate
investigations, proved that fatal septic poisoning can be produced in
animals by the products of organic decomposition, without the presence
of living organisms. Zweifel's experiments seem to have shown that
normal blood, when deprived of oxygen, in the absence of
micro-organisms, may acquire septic properties.

As stated by Belfield,[34] many experiments by Schmidt, Edelberg,
Kohler, Nencki, and others, have shown that septicaemia may be induced
by the injection into the blood of free fibrin ferment and other
substances, in the absence of minute organisms. To such an affection
some authors now give the name sapraemia, to distinguish it from
bacterial infective disorders.

[Footnote 34: _Lectures on the Relation of Micro-organisms to
Disease_, 1883.]

Griffini ascertained that mixed saliva, filtered through porous
plates, and thus containing no microbes, will still produce
septicaemia in animals, when subcutaneously injected. Colin (1876) has
denied the conclusiveness of the experiments of Chauveau, which have
been held to prove the particulate nature of variolous and vaccine
virus. Moreover, it is well known that eggs with shells unbroken are
tainted when placed near others which are unsound.

7. While Klebs and Koch maintain the definite specificity of each
minute microphytic organism, Naegeli and Billroth assert their mutual
convertibility. Burdon Sanderson avers[35] that "the influence of
environment on organisms such as bacteria is so great that it seems as
if it were paramount." Buchner, Grawitz, Greenfield, Pasteur, Wernich,
Thorne, Willems, Law, Wood, and Formad report experiments making it
appear that modification by culture is possible with bacilli and
micrococci, converting an innocent into a malignant parasitic
organism, or a death-producing microbe into one capable only of
causing {146} a transitory and not dangerous local affection; which
nevertheless secures to the animal thus treated immunity when
subsequently exposed to the deadly infection. Most interesting have
been the successes with such culture-inoculations obtained by Buchner,
Greenfield, and Pasteur with anthrax in sheep; by Pasteur also in
chicken cholera; and by Willems and Law[36] with the lung-plague of
cattle.

[Footnote 35: _Brit. Med. Journal_, Jan. 16, 1875.]

[Footnote 36: _N.Y. Med. Record_, June 18, 1881, p. 679. Exposure to
the air for a considerable period seems to be the agency chiefly
relied upon for what may be called the dynamic modification of these
microphytes. When cultivated in the depth of a liquid, so that air is
excluded, they are supposed to acquire a habit of obtaining oxygen by
decomposing organic substances, and thus act destructively upon the
cell-elements of living bodies. Analogous differences have long since
been observed in the study of fermentation between surface and
sedimentary yeast.]

In none of these cases is there reported any morphological change
whatever in the bacillus (Grawitz) or micrococcus (Wood and Formad);
the change in the effects noted, and, in the case of the micrococci of
malignant diphtheria, the acquired capacity of reproduction through
several generations, are all.

8. The immunity against subsequent attacks on exposure (similar to the
protection given by vaccination) continues to be without full
explanation upon any theory. But it is especially difficult to
reconcile it with the hypothesis of the infection being caused by, and
dependent upon, the presence of peculiar microphytes. Why should not
these, whether as parasites or as poisons, always produce the same
effects?

9. The view entertained by Thorne, Wood, and Formad, that a common
benignant affection, such as ordinary sore throat, may be converted
into a violent infectious disease--_e.g._ malignant diphtheria--by
modification of innocent micrococci into those with lethal characters,
through local or bodily conditions, is sufficiently contravened by the
great frequency of such conditions compared with the decided relative
rarity of such malignant epidemics or endemics.

10. Throughout all the investigations which have been, and are likely
to be, conducted, there remains the extreme difficulty, if not
impossibility, of total separation between the microbes themselves and
the matter of the vehicle in which they exist--the membrane, urine,
blood, virus, artificial culture-material, or whatever it may be. All
the effects ascribable to the disease germs may be, with no more
difficulty, attributed to the toxic action {147} of a portion, however
minute, of the soil in which they have lived, whose modifications must
be concomitant with those which they undergo. It appears necessary,
therefore, at the present time, to regard this whole question as still
undecided, with a predominance of probability, however, in favor of
the view that these minute organisms, or some of them, have a direct
and important relation of some kind to the causation of specific
endemic, epidemic, and contagious diseases. Altogether, the strongest
arguments are on the side of the view that the micrococci, bacilli,
etc. cause diseases, not as parasites, living upon their victims, but
as poison-producers infecting them.[37] The germ theory continues to
be in the position of a probable hypothesis, not in that of an
established doctrine of etiological science.

[Footnote 37: This comports much the best with the general natural
history of parasites on the one hand, and of venoms, ptomaines, etc.
on the other. Gautier, Ogston, and others have expressed the opinion
that microphytes may produce ptomaines.]

Practically, the result is nearly the same as if it were altogether
settled, since it is admitted on all sides that the presence of
microphytes (bacteria, micrococci, spirilla) coincides with those
conditions under which originate several of the most malignant
diseases. Measures which prevent the appearance or promote the
destruction of these minute organisms are at least often, and to a
great degree, preventive, if not curative, of such disorders; and the
glory of Jenner's discovery, by which the ravages of small-pox have
been made (potentially at least) controllable, seems not unlikely to
be paralleled by the achievements of Pasteur and others in a similar
preventive mastery over other maladies of men and animals. There is,
therefore, no branch of inquiry in connection with medical science
more worthy of being assiduously encouraged and extended. The present
may almost be said to be, in the history of medicine, an era of
myco-pathology.

For an exhaustive study of Etiology attention would now have to be
given to the modifying influences affecting the occurrence and
character of diseases in connection with age, sex, and temperament.
But, as neither of these is ever, per se, causative of any malady, and
they merely determine some modification of the action of morbid causes
when these occur, want of space must be our justification for leaving
them to be considered, in this work, in connection with the special
causation of the different {148} diseases which will be hereafter
described. A larger treatment of our present subject belongs rather to
hygiene than to practical medicine.


MEDICAL DIAGNOSIS.

For the purposes of the medical practitioner all professional studies
unite to the end of furnishing preparation for the diagnosis and
treatment of diseases. At the bedside the cardinal questions are, How
does the present condition of our patient differ from health? and,
What ought we to do to bring about his recovery?

Diagnosis involves three main directions of inquiry: 1, as to the
general bodily state of the patient; 2, morbid changes in particular
organs, tissues, or functions; 3, as to what name properly designates
the disorder, according to accepted nomenclature.

Pathology can never be out of view in connection with either the
theoretical or the practical study of diagnosis. But it is most
closely regarded when the last of these questions is before us, since
the names of diseases generally have a more or less distinct reference
to their pathological nature. Yet clinical observation always suggests
the early use of provisional terms for recognized groupings of morbid
phenomena; and sometimes these clinical designations remain for a long
time in use because of the imperfection of pathology.

We ascertain, in practice, the nature of a given case, first, by
considering its symptoms. These are those obvious evidences of
deviation from health which the patient himself is aware of, or which
the physician readily discerns or elicits by simple inquiry or
examination.

Secondly, taking the clue furnished by symptoms, a closer inspection
is made, with the intent of finding what is the actual state of
important organs, as the heart, lungs, liver, spleen, kidneys, and
alimentary canal.

Lastly, when these means fail to remove all obscurity, or when special
scientific investigation is practicable, instruments of precision are
employed, as the thermometer, sphygmograph, ophthalmoscope,
aesthesiometer, or aspirator; or by the microscope and chemical
analyses still more minute examination is made into the particulars of
the morbid processes present and their results.

We may subdivide diagnosis, then, into: 1, symptomatology; 2,
organoscopy or physical diagnosis; 3, instrumental diagnosis.


Symptomatology.

Semeiology (from [Greek: semeion], a sign) is a term much in use, with
essentially the same meaning as symptomatology, but less conveniently
distinctive, since it does not so well indicate the contrast between
obvious signs, or symptoms, and those more recondite, obtained by the
methods of physical diagnosis.

Signs of disease cannot be recognized as such except by one who is
{149} familiar with the appearances, actions, and manifestations which
belong to health. Nor can they be understood, so as to infer what they
mean, without knowledge of normal physiology on the one hand, and, on
the other, of the natural history of diseases. Physiology constitutes
the etymological grammar, symptomatology the vocabulary, and diagnosis
the syntax of practical medicine. Just as grammatical knowledge will
not enable any one to read or speak a language without acquaintance
with its words, so clinical observation is necessary to the physician
over and above all the knowledge he may have of physiology and
pathology. He must learn to know diseases by sight, or at least by
personal contact and observation.

Every one has, of course, a general familiarity with the state and
actions of his own and other bodies in health, yet a more exact
knowledge of the movements of respiration, circulation, secretion,
etc., as well as the form, size, and relative location of all the
organs of the body, is needed. Physiology and medical anatomy furnish
such information. The more thorough this knowledge is appropriated,
the better fitted the student is for practical diagnosis. For its
application, however, cultivation of all the perceptive powers is very
important. Some men have a genius for quick and clear discernment of
symptoms and for their interpretation, as well as for that of physical
signs. But all can much improve their senses, and their sagacity in
using them, by experience. For this, if for no other reason,
scientific training, in field or laboratory studies, affords the best
introduction to the work of the medical student and physician. The
traits most needed for success in diagnosis are exactness and
comprehensiveness. First, to be sure precisely what each sign is that
comes under observation; next, to overlook no existing symptoms or
physical signs; and, last, so to combine them into a mental map,
diagram, or picture, as to make a coherent and rational whole. This
nosogram may then be compared with the descriptions of standard
authorities, to find its place (if it has one) in technical
classification. First, however, ascertain the thing, the morbid state
or combination of states; afterward the name, or morbid species, when
practicable. It is always to be remembered that complication of
diseases, or at least the existence of some irregular manifestations
along with those which are characteristic, is more common than the
occurrence of purely typical cases. The portraits of most diseases in
the books are averages, like the composite class-photographs of
Douglas Galton. Not nearly every case will correspond with such an
average in all respects. Moreover, so great is the possible variety of
alterations among the different organs of the body that the chances of
two instances of disease being precisely alike in every particular are
hardly greater than those in favor of every move being the same in two
games of chess with the same opening.

In an essay like the present it is not easy to decide upon the best
manner of treating the subject before us. Too much or too little may
be said. With advanced readers the whole history of symptoms and
physical signs might be left to the special discussions occurring in
articles upon different diseases. But it may be taken for granted that
those who consult the present work will do so either at a
comparatively early stage of their studies or when time has made
desirable a renewal of what may have been once known and then
forgotten. Since, then, it is impossible {150} to anticipate what may
be the exact needs of either class, a somewhat elementary statement of
main facts appears justifiable here.

Following the natural method, we may suppose a call to visit a
patient. Arriving in his presence, the first question (mostly left out
of view and rarely expressed) may be, Is it a case of real or only
imaginary indisposition? Army medical officers, more than most others,
can appreciate the possibility of this inquiry sometimes disposing of
the whole case.

Supposing it to be real, is it an illness or an accident or other
injury? Is it severe or of trifling account? Acute or chronic? We
observe the position of the patient, lying quietly in bed, sitting up,
or walking restlessly about the room. Then the countenance is
observed--pale or flushed, tranquil or excited in expression. We feel
the forehead, touch the cheek and hand. Is the skin hot or cold, dry
or moist? The pulse is felt; the breathing also is counted.

Of the patient himself or of another (in serious acute cases better of
his care-taker, in another apartment) we ask questions whose answers
give us the general history of the case. When not before known these
should include his antecedent personal history, even extending to that
of the family, as far as can be learned. What tendencies have they, or
has he or she, shown by previous attacks and their results?

So we come to the present attack: When did it begin, and how? What
have been its prominent symptoms since? Questions are then to be put
concerning the heat of the body, appetite, complaint of pain, sleep,
movement of the bowels, discharge of urine: in the female,
menstruation; if married, pregnancy or parturition, how often and when
occurring last. Thus the practitioner is enabled to get a clue to the
diagnosis, to be followed out through his own observation and closer
examination. If the patient be a child and the attack be acute and
febrile, an early question must be as to its having passed or not
through the different diseases of childhood--viz. the exanthemata,
mumps, and whooping cough, and also what exposure to any of these it
may have been recently subjected to.

Going farther into particulars, let us review some of the possible
developments obtained in the above questioning of symptoms.

When lying in bed the decubitus may be significant, as, upon the back
with the knees drawn up in peritonitis; with the hands pressing the
abdomen in colic; tossing to and fro in the delirium of fever or of
early cerebral inflammation; on one side constantly in acute
inflammation of the liver or in pleurisy. Or the patient may be
obliged to be propped in a sitting posture (orthopnoea) from
heart-disease, asthma, or ascites, or leaning forward upon the back of
a chair or a pillow with aneurism of the aorta. More remarkable still
may be the subsultus tendinum of low fever, the opisthotonos of
tetanus, the respiratory spasms of hydrophobia, or the clonic
movements of epileptic, hysterical, or occasional convulsions.

In the face we see pallor in syncope and in anaemia in any of its
varieties and with varied associations; a general redness in some
cases of apoplexy and in remittent fever; flushing of the forehead and
eyes especially in yellow fever; dusky redness in typhus, and a more
purple hue in typhoid fever; yellowness in jaundice, in some cases of
remittent and in most of yellow fever; sallowness in cancer; a bright
central glow upon each cheek in early pneumonia or the hectic of
phthisis; a blue or ashen appearance in the collapse of cholera, and
blackish-blue in {151} cyanosis or carbonic acid poisoning; bronzed in
Addison's disease; puffy about the eyelids in Bright's disease; the
surface swollen, yet resistant to the touch, in myxoedema. The eyes
(one or both) glare prominently in exophthalmic goitre; squint in
advanced cerebro-meningitis; roll to and fro often in the prostration
of cholera infantum and in convulsions; are clear and bright in
phthisis; yellowish in hepatic disorder; dull and clouded in low
fevers; without expression in imbecility and general paralysis.

Contraction of the pupil is observed in inflammation of the retina or
of the brain, narcotism from opium (until near death) or eserine, or
apoplectic effusion near the pons varolii. Dilatation of the pupil is
seen in most cases of hydrocephalus and of apoplexy; in
nerve-blindness (amaurosis), glaucoma, cataract, and narcotism from
atropia, duboisia, or hydrocyanic acid. Inactivity of the pupil
(Argyll Robertson) under changes of light and darkness is common in
locomotor ataxia. Different states of the two pupils under the same
light show disorder, either ophthalmic or cerebral in site, or may
indicate pressure on the cervical sympathetic ganglia, as from aortic
aneurism.

In elderly persons we ought always to look for the arcus senilis,
which is a sign of a tendency to fatty degeneration. It is a ring, or
part of a ring, with ill-defined edges, best seen by lifting or
depressing an eyelid, at the junction of the cornea and sclerotic coat
of the eye. In some quite healthy old persons there may be seen at the
same junction a clearly-defined circular line of calcareous nature.
This must be distinguished from the true fatty arcus senilis.

Of the face we may also notice the pinched nose, hollow eyes, and
falling jaw of the facies Hippocratica, presaging death; the square
forehead of the rickety child (not common in this country); ulcers on
the forehead, scars at the mouth-corners, or copper-colored eruptions
in syphilis; the full, flabby lips of scrofula. In peritonitis or
gastritis the mouth is apt to be drawn up with a peculiar expression
of suffering and nausea. Very striking is the characteristic one-sided
appearance in facial palsy, from lesion of the seventh nerve. There
may be a smile, a frown, or other expression on the sound side of the
face, while the paralyzed side is quite immovable. As the seventh
nerve (portio dura) supplies the orbicularis muscles, its paralysis
(so often temporary) may cause inability to close the eye upon the
affected side. Ptosis, or inability to open the eye, involving the
levator palpebrae, which is innervated by the third nerve (motor
oculi) is more significant of cerebral lesion.

Even the ears may have language, as when their lobes are full and
glistening red in the gouty diathesis, or wrinkled in prolonged
cachexiae, or when they are running with discharges in the struma
(scrofula) of childhood. The hair becomes dry and lustreless in
phthisis, and falls out during convalescence from many acute diseases.

If we look at the gums in a case of lead-poisoning, we may expect to
find a blue line along their edges. Scurvy is betokened by a swollen,
spongy, and easily-bleeding state of the gums. Many scorbutic cases,
however, lack this so-called pathognomonic feature. It may be
remarked, by the way, that absolutely pathognomonic signs of
particular diseases, never absent and exclusively seen in them, are
very few. Albuminuria, for example, is not always present in Bright's
disease, and is {152} also met with in a number of other affections.
Sugar in the urine may follow inhalation of chloroform or an attack of
cholera, as well as diabetes mellitus. Rice-water discharges may be
absent in the collapse of cholera, and patients may die with yellow
fever without black vomit. Still, these symptoms have great diagnostic
value, and, taken with others associated with them, may often enable
us to attain to a diagnosis of much importance.

Perfect teeth in an adult in this country are rather the exception
than the rule. In the notched incisors of inherited syphilis, however,
there is something quite distinctive. The notches in Hutchinson's
teeth are vertical, not horizontal.

Old as medicine is the examination of the tongue in disease. It may be
protruded with difficulty, as in low fevers, in apoplexy, and in
cerebral paralysis (bulbar sclerosis, glosso-labio-pharyngeal
paralysis) or thrust to one (the paralyzed) side in hemiplegia. It is
pallid in anaemia; yellow in bilious disorder; red in glossitis (then
swollen also), in scarlet fever, and in gastritis; furred in
indigestion, gastro-hepatic catarrh, and the early stage of various
febrile attacks; dry, brown, cracked, or fissured in typhus or typhoid
fevers and in the typhoid state of malarial remittent fever; bare of
epithelium in advancing phthisis and in imperfect convalescence from
severe acute diseases. Coldness of the tongue is one of the worst
signs in the collapse of cholera.

As we examine the throat internally we look for signs of faucial
inflammation in redness and swelling, with or without enlargement of
the tonsils, or relaxation and elongation of the uvula, or ulceration,
or the gray or brown membranous deposit of diphtheria. In the mouth of
a child we may find the little white vesicular patches called aphthae,
the curd-like exudations of thrush, or possibly the much worse grayish
ulcerations of cancrum oris, or the rarer ashen sloughs of gangrene of
the mouth.

Outside of the throat we must remember the significance of glandular
swellings or scars of suppurated glands in children; nor overlook, if
present, stiffness of the muscles, or torticollis, or goitrous
enlargement of the thyroid gland. Observation should be made also of
the site of the carotid artery on each side, and of the jugular veins,
since aortic regurgitation may be indicated by violent action of those
arteries or tricuspid regurgitation by pulsation of the veins in the
neck.

Long before vaso-motor physiology had any place in science the pulse
was known to afford valuable indications in disease. Either of the
accessible arteries will answer instead of the radial; its convenience
merely makes the wrist the common place of comparison. By careful
examination of the pulse something may be learned of several of the
factors concerned in its production. These factors are--1, the
muscular force of the walls of the heart; 2, the state of the cardiac
valves; 3, the muscularity of the arteries; 4, the elasticity of the
arterial coats; 5, the state of the capillary circulation; 6, the
qualities of the blood; 7, the condition of the nervous system as to
excitability or apathy.

A feeble heart must induce a feeble pulse. Moderate debility may be
attended by slowness of the pulse, but usually a weak circulation is
marked by frequent, small beats, like the vibrations of a short
pendulum. A strong heart-beat (other things being equal) is relatively
slow, with a proportionate pause after the second sound.

{153} Valvular lesions produce various effects upon the pulse. Most
notable are the irregularity connected often with mitral insufficiency
and the jerking pulse (Corrigan) of aortic regurgitation.

Believing, as the present writer does, in the existence of a true
arterial systole following and supplementing the ventricular
contraction,[38] it must be urged that a vigorous muscularity in the
arteries promotes strength in the pulse--not by resistance, but by
auxiliary propulsion of the blood. Another condition altogether is
tonic, spasmodic contraction of the arteries. This is not often met
with pure and simple, but a measure of it is seen in the corded or
wiry pulse of acute enteritis or peritonitis.

[Footnote 38: This view, although advocated by Sir Charles Bell,
Legros and Onimus, Hermann of Zurich, and others, is opposed to the
most prevailing vaso-motor physiology. Several complications and some
contradictions in pathological discussion at the present time would be
cleared up by the abandonment of the now commonly-held stopcock theory
of arterial function, which has really nothing whatever to support it
except the misinterpretation of some experiments upon arteries made
many years since.]

Deficient elasticity of the arteries is not easily separated in
observation from muscular relaxation. When arteries undergo
degeneration (atheromatous, fatty, or calcareous), their middle coat
suffers the deterioration of both elastic and muscular tissues, these
being substituted by materials either more or less yielding, and
always less resilient, than the natural fabric of the vessels.

The influence of the condition of the capillary circulation upon that
of the arterial system and the heart is manifest in inflammations. By
reflex excitation the arteries are made to contract actively and impel
the blood more forcibly than in the normal state toward the centre of
impeded nutrition (stasis). This has been abundantly proved by the
comparison of the amount of blood flowing through the arteries of a
sound limb and those of its fellow, when the latter is the seat of a
violent acute inflammation.

Blood-states also affect the pulse by the differences in direct
stimulation to which the heart and arteries are subjected according to
the qualities and composition of the blood. It is probable that the
fever-pulse of typhus, typhoid, the exanthemata, septicaemia, and
pyaemia has its origin in morbid conditions of the blood, acting in a
twofold manner--directly upon the heart and arteries themselves, and
mediately through the vaso-motor ganglia.

Lastly, the nervous system stands in an important relation to the
action of the heart and arteries, and thus to the pulse. In a nervous,
excitable person, changes in the rate of the pulse may take place,
with slight significance, which in a different constitution might be
of serious import.

To understand the language of the pulse care must be taken in several
respects:

1. Both wrists should be felt. Sometimes there is an abnormal
variation in the course of the main radial trunk which may pass over
the thumb. Again, an aneurism may cause a great difference between the
two radial pulses, or, possibly, an embolus may occlude one of the
radial vessels, annulling its pulsation.

2. Other arteries also, especially the carotids, should be
examined--in all obscure cases at least. Visibly beating, distended,
and tortuous temporal arteries are occasionally met with. They are not
pathognomonic of any one malady, although often referred to the gouty
diathesis. They {154} may attend irregular malarial attacks, or may be
connected simply with a hyperaemic state of the brain.

3. The heart's impulse should always be compared with the arterial
pulsation. The former may be strong and regular, while the latter is
small, feeble, or intermittent. Something must then be wrong, either
in the aortic valves or in the arterial system.

5. On account of possible nervous agitation, the pulse should usually
be examined more than once, during each visit to the patient.

6. Sex, age, position of the body, and time of day must all be taken
account of. In men the average rate of the pulse is between 65 and 75
per minute; in women, between 70 and 80. The pulse-rate of early
infancy varies from 100 to 120, and is very easily hurried. That of
old persons is commonly between 60 and 70, until, at a very advanced
age, with debility, its frequency may be increased, especially upon
exertion. Lying down, we find the slowest pulse; sitting, somewhat
more rapid; and most so in the standing position. In health the time
of day makes no constant difference apart from the effects of food and
exercise. In disorders attended by fever there are important changes
to be regularly observed. Excepting the variable paroxysms of
remittent and intermittent, which are a law unto themselves, in
febrile affections the pulse may be expected to be slowest in the
morning and most excited in the early part of the night. A diminution
of this difference is a favorable sign. Sleep generally slows the
pulse decidedly. The ordinary statement is, that the pulse is always
slower during sleep, but I have several times found that in states of
exhaustion without fever it may be considerably more rapid while the
patient is asleep. Nothing is more sure to increase the strength and
rapidity of the pulse than high temperature.

7. Very important is the relation between the pulse and respiration.
Normally, four pulsations occur to each respiratory act. In pulmonary
affections, while the circulation is often disturbed pari passu with
the breathing, it may be quite otherwise. Great acceleration of the
rate of breathing, with little increase in the rapidity of the pulse,
should lead us to suspect disease involving the respiratory organs.
Conversely, a much hurried or otherwise perturbed pulse, with little
or no change in the breathing, points toward the heart as either
functionally or organically the seat of disorder.

Let us further consider, briefly, the kinds of pulse to be met with
and interpreted in practice.

A natural pulse is always, per se, a good sign. Yet in the history of
a disease usually so well marked as yellow fever some fatal cases have
been recorded (walking cases) in which the pulse, almost to the last,
was natural.

Strength of the pulse, to a certain degree, belongs to it normally.
But this is often exaggerated, and we may have the strong, hard, full,
perhaps bounding, pulse of an inflammatory affection (of the brain,
for example, or of the joints in acute rheumatism) in a person of
vigor. A bounding pulse often accompanies mere palpitation of the
heart, whose source may be the sympathetic influence of indigestion or
nervousness. A similar pulse is apt to be constantly present in
hypertrophy of the heart. In this case it is made more forcible as
well as more rapid by {155} active exertion; while palpitation,
without organic trouble, is usually diminished by moderately active
exercise.

A full pulse is not always strong, nor is a small pulse necessarily
weak. Mention has been made already of the tense, corded pulse met
with in acute peritonitis, and sometimes in enteritis. Gastric
inflammation, with nausea, may exhibit a depressed pulse, weak and but
little accelerated. Under still other circumstances we may find a full
pulse which is soft, easily compressible, even gaseous. Most
frequently a feeble pulse is rapid, and a very rapid pulse is weak.
Slowness, in marked degree, attends apoplexy, opium narcotism, and
fracture of the skull compressing the brain. Functional disturbance of
the heart may occasionally exceed in effect these causes of
retardation. I have met, under such circumstances, with a pulse of 20
in the minute; one of 18 has been recorded. A few apparently healthy
persons have habitually a pulse with but 40 or 50 beats in the minute.

Quickness in each beat may occur, while a long interval makes the rate
per minute slow. The jerking pulse of aortic regurgitation is the most
remarkable example of this. Galabin asserts that without imperfection
of the valves of the aorta a decidedly abrupt pulse may attend great
lowering of arterial tension. Something of the same kind may be
noticed in the temporarily excited pulse of very nervous subjects
under agitation.

Dicrotism, or reduplication of the pulse-beat, is not uncommon in
typhus and typhoid fever. Here relaxation of the heart as well as of
the blood-vessels appears to allow a momentary interruption in the
succession of the arterial upon the cardiac systole.[39]

[Footnote 39: An exceptional phenomenon, noticed by a few observers,
is the recurrent pulse; _i.e._ a pulsation felt below the finger,
whose pressure interrupts the flow of blood through an artery. It may
be explained by supposing unusual fulness of the vessels (local, if
not general) with, at the same time, relaxation of their walls;
bearing in mind, also, the manner of anastomosis of the radial and
ulnar branches which favors recurrence.]

Intermittence and irregularity of the pulse are not exactly the same
thing. Occasional intermittence may be merely a nervous symptom or a
muscular twitch of the heart, like the twitches now and then occurring
without significance in voluntary muscles. Persistent intermittence,
with feebleness of the pulsations (these being generally somewhat
rapid), is among the signs of dilatation of the heart.

It is possible for intermittence of the radial pulse to accompany
regularity in the heart-beat. This usually results from narrowing
(stenosis) of the aortic valvular outlet from the left ventricle. Only
a certain number of impulses fairly reach the more distant arteries.
This symptom may result also from fatty degeneration of the heart.

Absence of pulse in one radial vessel, while it is present in the
other, shows the presence of an obstacle to the circulation on one
side, which may be an aneurism, or an embolus plugging the artery.

Irregularity of the pulse, a total derangement of its rhythm, while
not often important in young children, is a serious symptom at other
times of life. In one disease most common in childhood, acute
hydrocephalus, the pulse in the first stage is apt to be hard and
rapid, in the middle stage slow and tolerably full, in the third
rapid, feeble, and often irregular. Mitral disease frequently presents
considerable irregularity of the pulse; and so does dilatation, even
without mitral lesion. Brain trouble, especially late in life, whether
structural or functional, may produce the {156} same symptom. B. W.
Richardson has pointed this out as one of the effects of the excessive
use of tobacco, even in young persons.

The pulse of continued, relapsing, and remittent fevers is, during the
febrile exacerbation, rapid (100 to 120); in the earlier part of the
attack full, but only moderately hard, or even soft and yielding. As
the attack passes its height and critical defervescence occurs, the
pulse grows slower, unless great prostration has supervened; in which
case it increases in rapidity, while it fails more and more in fulness
and resistance.

The pulse of the moribund state is nearly always small, very rapid
(130-150), and thready, without force or fulness. It may become
imperceptible before death. A pulse of 140 beats in the minute is
always alarming; if much beyond that rate the case is desperate. A
pulse of more than 150 beats in the minute is very difficult to count
accurately.

Exophthalmic goitre is attended characteristically by a full, somewhat
rapid, and bounding pulse, the cardiac impulse being also
proportionately violent and extended. Exercise much increases this
hyper-pulsation.

Pulsation of the jugular veins is ordinarily explained by tricuspid
regurgitation, a portion of the blood being sent back to the vena cava
with an impulse reaching to the jugulars. In some instances, however,
as the writer has repeatedly observed, jugular pulsation takes place
without any abnormality in the action or condition of the heart, from
a local inflammation (as tonsillitis) causing a marked exaggeration of
the muscular contractility resident in the larger veins.

Retardation of the flow of blood through the veins is manifest during
the collapse of epidemic cholera. On pressing the blood back in a vein
upon the hand, for example, and then lifting the finger, instead of
the movement being, as in health, too swift to be seen, it is so slow
as to be easily followed.

Capillary movement may be estimated in a similar manner. If it be very
sluggish, pressure upon the cheek, forehead, or hand will cause a
pallor which remains for some seconds, instead of disappearing at once
when the pressure is withdrawn. This is, it may be noticed, entirely
different from the pitting upon pressure, without much if any change
of color, in local oedema or general anasarcous effusion. The tache
meningitique of Trousseau is a pink or rose-red line left for a time
after drawing the finger across the forehead or abdomen in cases of
acute hydrocephalus (tubercular meningitis).

Respiration must be watched carefully in all cases of disease.
Normally, in the adult, while at rest, from 16 to 18 respiratory
movements occur in each minute. The number is somewhat greater in
women, and is considerably increased in children, at birth being about
40 in the minute. Men breathe most by the diaphragm; in women there is
a greater lifting of the ribs. In either sex a disorder attended by
pain in breathing may modify this proportion. If pleurisy, for
example, be present, the ribs will be but slightly lifted, abdominal
breathing taking predominance. When peritonitis makes every movement
of the abdomen painful, costal respiration is maintained almost alone.
Likewise, a unilateral pleurisy or pneumonia will check the
respiration on the affected side, with an increased movement on the
sound side. This difference is less manifest to the eye than to the
ear in auscultation. In all febrile {157} affections respiration is
hurried proportionately with the pulse, unless some complicating local
disorder disturbs the relation.

Dyspnoea may be produced by many different causes, whose possibility
must be remembered in its interpretation as a means of diagnosis. In
asthma violent efforts are made to compel the entrance of air into the
lungs by the intercostal muscles and diaphragm, aided by all the
accessory muscles of respiration, including the sterno-cleido-mastoid
and others of the neck. Expansion of the nostrils may occur in
sympathy with these efforts. Yet the amount of resistance may be shown
by a partial sinking-in of the lower ribs, as well as by the patient's
distress. These last signs are sometimes very marked in the collapse
of one or both lungs now and then occurring in whooping cough.

Croup induces a similar struggle for breath, although the obstruction
is differently located. Early in the croupal attack a hoarse sound may
accompany each inspiration and expiration. Later, when the danger to
life from apnoea becomes more imminent, a hissing or whistling sound
succeeds. This last-mentioned kind of sound results temporarily, also,
from the spasmodic obstruction to breathing in laryngismus stridulus.

Besides the affections of the lungs which impede respiration (as
pneumonia, hydrothorax, etc.), we may have dyspnoea induced by
extra-pulmonary causes, such as dilatation of the heart, aneurism of
the aorta, mediastinal cancer, pleuritic effusion; also by abdominal
dropsy, extreme elephantiasis, etc. Mention need hardly be made here
of respiratory obstruction from defective or injurious qualities of
the air, threatening or producing asphyxia.

Sighing respiration takes place in heart disease not infrequently. A
peculiar modification of the breathing movements has been associated
especially with fatty degeneration of the heart. From the
distinguished authors who first described it this is called the
Cheyne-Stokes respiration. Intervals of suspension of breathing occur,
after which short, shallow inspirations begin, and gradually increase
for a time in depth; then they grow shorter and shallower again, until
apnoea is reached. Such a cycle may occupy from half a minute to a
minute and a half, with from fifteen to thirty increasing and
decreasing respirations in all. It has been shown by several observers
that this type of respiration is not peculiar to fatty degeneration of
the heart. It has been met with in cases of cardiac dilatation, aortic
atheroma, cerebral hemorrhage, tubercular meningitis, and uraemia.

Sometimes a kind of dyspnoea common in advanced disease of the heart,
especially in mitral lesion with dilatation, has been confounded with
this. Here the breathing is constantly labored (orthopnoea); but the
patient from time to time dozes off into an imperfect sleep, in which
the breathing almost entirely ceases. Then he is awakened with a start
of distress, perhaps out of a painful dream. This succession of dozing
apnoea and waking dyspnoea belongs to a late stage of heart disease,
and usually ends in death.

Stertorous respiration is familiar in apoplectic coma, as well as in
that of brain compression from injury or from opium or alcoholic
narcotism. In uraemic coma true stertor is less apt to be observed;
sometimes the respiration in this condition has a hissing sound.

Along with the movements of respiration we may notice that the breath
{158} is hot and has a heavy odor in the early stages of all febrile
disorders. Disagreeable breath is common, however, in persons not ill,
from bad teeth or from indigestion. It is worst of all, putrid, in
gangrene of the lung. Certain cases of chronic or subacute bronchitis
(as well as of ozaena) also have very offensive breath. Coldness of
the breath is a very bad sign; it is observed sometimes before death
in the collapse of cholera.

Hiccough (singultus) is a spasmodic affection of the diaphragm. It is
innocent, though annoying, in most cases, resulting from indigestion
or from nervous disorder; in children, occasionally, from long crying.
When it takes place in cases of general prostration it betokens
threatening depression or exhaustion of vital energy.

The voice is mostly altered by serious disease. It may be feeble and
whispering, from debility; hoarse, from laryngeal inflammation and
tumefaction; thick, from cerebral oppression; lost (aphonia), in some
cases of chronic laryngitis and in paralysis of the vocal muscles. The
manner of articulating words is often changed in disorders of the
nervous system. A marked example of this is the monotonous scanning
speech of cerebro-spinal sclerosis.

Cough is an extremely variable symptom, always to be understood in
connection with the attendant circumstances. Usually, however, the
character of the cough itself is more or less distinctive. A dry, hard
cough may be merely sympathetic or nervous, or it may belong to the
first stage of acute bronchitis. A hacking cough, with little
expectoration, is not infrequently observed for a time in incipient
phthisis. Pneumonia has, if any, a short and rather sharp cough.
Progressing bronchitis is recognized by the deepening and greater or
less loosening of the cough. In advanced phthisis there are
distressing spells of deep, laborious coughing, especially in the
night or in the morning after sleep. Croup is known (whether sporadic
or in the form of laryngeal diphtheria) by the barking cough of the
early stage and its whistling character toward the fatal end. Nearly
the same sort of hissing or whistling sound in breathing has been
mentioned already as occurring in laryngismus stridulus. Paroxysms of
coughing, with or without whooping, are pathognomonic of pertussis.

Expectoration often affords important signs. Briefly, it may suffice
to say here that it is mucous, whitish, or colorless in early
bronchitis; more or less yellowish and muco-purulent in severe and
protracted bronchitis; rusty, from admingling of the coloring matter
of blood, in pneumonia, early and middle stages; bloody and
muco-purulent in early and of heavy roundish (nummular) masses in late
pulmonary phthisis; putrid, rotten, in gangrene of the lung.

Continuing our survey of obvious symptoms, we must now take account of
the conditions of the general surface of the body. Temperature is of
great consequence. Most precisely determinable by the thermometer, the
touch, when educated, will give very useful indications of its
changes. It is difficult, and not commonly desirable, to separate
variations of moisture from those of temperature. Reserving for
another place the special consideration of medical thermometry, it may
be here said that the skin is hot and dry in the typical condition of
fever, whatever its special associations. Heat and moisture of the
skin are more often met with together in the fever of acute articular
rheumatism than in any other {159} affection. As a rule, perspiration
lessens febrile heat. Copious (colliquative) sweating is habitual in
many wasting diseases, notable in pulmonary phthisis. It is then a
sign of great general relaxation of the system.

Coldness of the surface attends prostration, either from temporary
collapse or from positive exhaustion. The skin is perceptibly cold in
the algid stage of cholera. It may be so in very severe cases of
sporadic cholera morbus. In the chill of intermittent, while the
patient has the subjective sensation of coldness, his temperature is
seldom reduced, and is often higher than natural, although lower than
during the febrile exacerbation.

The color of the skin is pallid in anaemia, phthisis, dropsy, etc.,
and in syncope; ashen or livid in cholera collapse and in the cold
stage of pernicious malarial fever; yellow in jaundice, remittent, and
yellow fever; sallow in chlorosis, cancer, and chronic dyspepsia;
purple, almost black (especially the lips and ends of the fingers), in
asphyxia; dark, as if stained with ink, after long use of nitrate of
silver; bronzed in Addison's disease; bright red in scarlet fever,
etc. The eruptions of this and other exanthemata, and of the different
cutaneous diseases, will be best considered in the special articles
treating them of in this work.

Odor is perceptible and peculiar (though not easily described) in some
bad cases of typhus fever and of small-pox; less often in aggravated
chlorosis. Lunatics and paralytics (especially when assembled together
in institutions) often give off a noticeable smell. Most distinct,
however, is the cadaverous odor, sometimes perceptible for hours
before death. Corroborative of this, in summer, is the flocking of
flies around the bed of a dying patient. In a hospital ward this
selection amongst a number of patients may be quite observable.

Emphysema, from the presence of air in the connective tissue under the
skin, is rarely met with except as the consequence of an injury or of
local gangrene.

Oedema is local watery effusion, which may have various causes and
significance. Anasarca must have a general causation, either connected
with the state of the blood or with disorder of the heart, kidneys, or
liver, or of more than one of those organs at once. Pitting on
pressure is the sign of watery effusion. Soft crackling under the
touch distinguishes emphysema. A firm enlargement of the surface of
the face and upper part of the body occurs in myxoedema.

Swellings of all kind must be carefully observed, and their nature
inquired into--whether they be inflammatory or other chronic
enlargements of joints, tumors, fibrous, fatty, or cancerous,
aneurisms, hernial protrusions, or of any other character. In
protracted disease of the liver (cirrhosis) it is not uncommon to find
the superficial abdominal veins dilated and tortuous.

Abdominal enlargement may result from adipose accumulation (obesity),
distension of the bowels with wind (meteorism), ascites, ovarian
cysts, cancerous or other tumors, aneurism of the aorta, abscess,
retention of urine, or pregnancy. By the methods of physical
diagnosis, along with careful inquiry into the history of each case,
we are to make out the distinctions amongst these different
conditions.

Emaciation always marks either defect of nutrition or morbid excess of
tissue-waste. It is counterfeited in the sudden collapse of malignant
{160} cholera, and exaggerated in appearance during the analogous
condition of cholera infantum. On recovery from these states,
especially the latter, roundness and fulness of the face and limbs may
return much too soon for the actual restoration of fat and flesh. A
young child may be plump and chubby to-day, seemingly wasted with
acute illness to-morrow, and, if soon relieved, the next day almost as
rotund as ever.

Continued diarrhoea, phthisis pulmonalis, mesenteric disease, cancer,
and aneurism of the aorta are among the most frequent causes of great
emaciation. Sometimes, as in progressive pernicious anaemia, we are
struck with the comparatively slight degree of wasting of the body
while the disease is advancing toward death.

In myxoedema there is a swelling or general enlargement, especially of
the upper portions of the trunk. This is not anasarcous, but depends
upon a morbid change in the connective tissue throughout the body.

Articular enlargements may be (particularly in the knee in children)
scrofulous, or gouty (in the smaller joints), rheumatic, with
evidences of inflammation, acute or chronic; or, what is not well
named, rheumatoid arthritis. In this last affection there is a gradual
swelling and stiffening, with but little inflammation, of several,
sometimes all, the joints of the extremities. Locomotor ataxia is in
some cases attended by a degenerative alteration in one or more of the
larger joints.

The limbs may furnish to the eye many expressive signs of disease or
disability. In the listlessness of one arm and hand, while the other
can perform various movements, we see reason to suspect hemiplegia. If
the fingers are rigidly contracted, as well as powerless, we have this
diagnosis confirmed, whether the rigidity be early or late in its
stage. We must then look for a similar condition of the lower
extremity on the same side. Paraplegia and general paralysis have
their more extended (bilateral) indications in like manner.
Characteristic also are the wrist-drop, from paralysis of the
extensors of the hand, in lead-palsy; weakness or incapacity of the
flexors and extensors in writer's cramp; the hand fixed helplessly in
the position for writing in paralysis agitans (advanced stage); the
main en griffe, with shrunken muscles and drawn tendons, of
progressive muscular atrophy (wasting palsy). In the legs at first and
chiefly, but in time also in the arms, increase of bulk with loss of
power in the muscles shows the existence of pseudo-hypertrophic
muscular paralysis.

Gouty fingers have their joints not only swollen, but distorted by
deposits of urates and carbonates. Clubbed finger-ends, in the adult,
are seen mostly, with incurvation of the nails, in advancing
consumption. The nails are sometimes striated after attacks of gout,
the lines disappearing gradually during the interval. In many acute
diseases, transverse ridges are noticeable on the nails, marking the
date when their growth was arrested and subsequently resumed. These
are specially remarkable after attacks of relapsing fever.

A tendency to dropsical effusion is generally first shown, besides a
puffiness of the face, in the feet and ankles, the shoe or slipper
marking off the enlargement above its margin. Often this has no other
cause than debility, with a watery condition of the blood. Varicose
veins, with old and resultant ulcers, are also among the possible
things to be found in examination of the legs and feet.

{161} Movements of the hands are incessant and jerking in chorea;
perpetually trembling in delirium tremens, and often in one arm and
hand only, in paralysis agitans; with tremor, seen in voluntary
motions alone, in multiple cerebro-spinal sclerosis. More unusual is
the rhythmical closing and opening of the hand, successively, of
athetosis.

In the walk of patients able to be upon their feet there may be much
significance. A hemiplegic subject will circumduct the feeble limb
after the other; one suffering with paraplegia will shuffle the feet
slowly along the floor; the hysterical paralytic drags the lame limb
behind the other; the patient with spastic spinal paralysis rises on
his toes in walking, with his legs held close together; the shaking
paralytic rather trots forward, with the body bent; and the subject of
locomotor ataxia lifts his feet and kicks out forward or sideways,
then bringing down the heels with a stamp at each step. In progressive
muscular atrophy and advanced pseudo-hypertrophic muscular paralysis a
waddling or rolling gait is seen. Choreic patients are very irregular
in their walk, as in all other movements. Hip disease (coxalgia) shows
itself in a child by its lifting the pelvis and limb of the affected
side and bending the knee, so as to touch only the toes to the ground.
Club-foot and other deformities require no description in this place.

Sensibility of the extremities and of other parts of the surface of
the body needs to be examined into, with all its possible variations
(hyperaesthesia, anaesthesia, analgesiae, etc.), especially when the
nervous apparatus is for any reason supposed to be involved. Motions
of an unusual character must likewise be carefully noticed.
"Westphal's symptom" is regarded as having considerable diagnostic
value. It is otherwise called the tendon-reflex, with its
modifications. When a person in health is seated with one leg crossed
over the other or with the legs dangling over the edge of a high bench
or table, and a sudden blow is struck upon the tendon of the patella,
the leg and foot will be spontaneously jerked forward. In locomotor
ataxia, even from an early period, this tendon-reflex is abolished. In
spastic spinal paralysis (lateral spinal sclerosis) it is exaggerated.
Quite analogous to this is the ankle-clonus. This is obtained by
firmly flexing the foot and then tapping sharply upon the tendo
Achillis. The foot is then involuntarily extended and flexed several
times in succession. There is more doubt in regard to the associations
of this symptom than as to the knee movement, but it has been
clinically shown to be exaggerated in spastic spinal paralysis.

At our first acquaintance with a case of disease, while making inquiry
into its nature, the genital organs must not be forgotten. Not that we
need always make examination of them, but any pointing in symptoms
toward them must be borne in mind, so as to guide us in or toward
further procedures in diagnosis. In making, in obscure cases, a
diagnosis by exclusion, we are sometimes driven to a scrutiny of the
genital system.

We have now, however incompletely, touched upon the greater number of
obvious signs or symptoms which a view of a patient would furnish
without making minute inquiry of himself or others concerning his or
their knowledge of the illness. Such are the objective signs of
disease, which must be still more exactly and extensively discerned
and understood by means of the processes of physical and instrumental
diagnosis. {162} But the subjective symptoms also, and all those
observed and described by the patient and his or her friends, must
receive very careful attention. Much practical skill may be shown by
the kind of questions asked and the use made of the answers given.

First, as to the alimentary apparatus:

Taste is very commonly altered in disease, being sour in indigestion,
bitter in disorders of the liver, saltish in haemoptysis, rotten in
gangrene of the lungs.

Dryness of the mouth is the rule in fevers. Sometimes the saliva is
viscid and adherent. Increased flow or salivation was formerly
frequent in practice under large doses of mercurials. Jaborandi or its
alkaloid pilocarpin will generally produce it. Iodide of potassium
occasionally has the same effect in less degree.

Loss of appetite nearly always attends serious diseases of any kind.
Excessive craving for food (bulimia) is rare. Tapeworm accounts for it
in some instances. Desire for strange articles of food, as
slate-pencils, ashes, etc., is met with in some instances of chlorosis
and of hysteria. A return of natural appetite is one of the best signs
toward the close of any acute attack of illness.

Thirst is seldom absent in fever. It is also usually present in the
state of collapse, as from cholera, pernicious intermittent, or the
shock of severe (especially railroad) injuries.

Dysphagia or difficulty of swallowing may result from simple debility,
as in the moribund state; inflammation of the fauces, tonsils, or
pharynx; stricture of the oesophagus; obstruction by a foreign body or
by a cancerous or aneurismal tumor; retro-pharyngeal abscess;
paralysis of the muscles of the throat, such as sometimes follows
diphtheria. Soreness of the throat is present in some, but not in all
of these examples of dysphagia, being most marked in the inflammatory
condition of pharyngitis, tonsillitis, scarlet fever, and diphtheria.
Ulceration of the throat should always be carefully looked for, and if
present investigated to ascertain whether it is simple, diphtheritic,
or syphilitic. We must be careful not to mistake a mere local
accumulation of mucus, or aphthous vesicle, or the curd-like formation
of thrush or muguet, either for ulceration or pseudo-membranous
deposit. Aphthae and thrush are most frequently met with in children,
though small aphthous ulcers frequently appear toward the close of
wasting, and especially cancerous, affections. If there be a doubt,
pass a moistened hair pencil lightly over the apparent deposit, or
allow the patient to gargle the throat with water, and then re-inspect
it.

Many causes may produce nausea and vomiting, which almost always occur
together; that is, vomiting rarely takes place without previous
nausea, although the latter may exist without the former. In the
manner of vomiting there are some differences more or less
characteristic, as the distressing retching of sea-sickness and of
tartar emetic or other irritant poisoning, and the spasmodic
out-spurting of rice-water fluid in malignant cholera. The matter
vomited is often very important in diagnosis. In mere indigestion the
food taken is apt to come up, and the same may happen in flatulent
colic. When the liver is involved, as in bilious colic, bile also is
ejected. Nothing peculiar exists in the ejecta of morning sickness in
pregnancy. The ejecta contain mucus in gastritis, blood in ulcer and
in cancer of the stomach, stercoraceous {163} material in obstruction
of the bowels, black vomit in bad cases of yellow fever. Hysterical
vomiting sometimes closely imitates the latter in appearance. Other
affections attended by vomiting are cholera morbus, remittent fever,
brain disease, Bright's disease of the kidney, etc.

Spitting blood may be either haematemesis or haemoptysis proper. If
the former, nausea generally precedes the ejection of the blood by
vomiting, and it is apt to be mingled with food partly digested. It is
coughed up, bright red and frothy usually, when coming from the lungs
or bronchial tubes. But blood may proceed from the gums or throat, or
may run back through the posterior nares from the nose, and then it
gives alarm by seeming to proceed from the chest. It is necessary to
inquire very particularly into all such possibilities in every case of
hemorrhage.

Between vomiting of blood from ulcer and from cancer of the stomach we
have mostly these distinctions: in ulcer it follows soon after taking
food, in cancer (this being generally at the pylorus), an hour or more
after eating; ulcer is attended also by tenderness on pressure at a
certain spot over the stomach, without tumor; cancer presents a tumor,
with much less marked tenderness on pressure. By aid of the microscope
in examination of the matter vomited this diagnosis may be completed.

Constipation is an exceedingly frequent symptom under many and diverse
circumstances. Pathologically, we account for it in several ways: 1,
torpor of the muscular coat of the intestinal canal; 2, deficiency of
secretion in the glands of the bowels and in the liver; 3, imperfect
innervation of the abdominal organs; 4, mechanical obstruction, as by
a foreign body, intussusception, strangulated hernia, cancerous or
other tumor, stricture of the rectum, etc. Dyspeptic persons are
ordinarily constipated. So are almost all patients at the beginning of
attacks of measles, scarlet fever, small-pox, and other acute febrile
maladies. Typhoid fever is scarcely an exception to this; although the
bowels in that affection become loose after a few days, they seldom
are so at the very beginning of the attack. Sea-sickness is commonly
accompanied by total or nearly total inaction of the bowels, the
secretion of the intestinal glands being almost null, often for many
days together. Torpor of the brain is sometimes attended by marked
constipation. The latter may be a contributing cause of the former, as
in certain severe cases of scarlet fever, in which threatening coma
may be relieved by active purgation. We must not, however, occupy
space here by attempting to enumerate the many conditions under which
constipation may present itself as a symptom.

Almost as various are the associations of the opposite state of the
bowels, diarrhoea. Excessive or abnormally frequent discharges from
the bowels may be either fecal, bilious, mucous, membranous, purulent,
bloody, fatty, or watery, and they may occur with or without pain and
straining (tenesmus).

If, with frequent disposition to pass something, only small quantities
of bloody mucus escape, with pain and bearing down, we recognize
dysentery. When, instead, a large quantity of colorless fluid, with or
without floating flakes (rice-water), comes from the bowels at short
intervals, with vomiting of the same sort of material, we suspect
epidemic cholera, and must inquire for corroborative or corrective
indications in {164} reference to that suspicion. Very bad cases of
cholera morbus also may, at a late stage, present this symptom. So may
exceptional cases of pernicious malarial fever. The diarrhoea of
typhoid fever exhibits usually liquid stools of a brownish color
(gutter-water passages). Occasionally, hemorrhage from the bowels adds
to the danger of this fever, as well as to that of malarial remittent
fever. In phthisis pulmonalis, at a late stage, colliquative
diarrhoea, like colliquative perspirations, shows the breaking up of
the system by excessive waste. Very foul, offensive discharges from
the bowels may always be understood as showing that in the alimentary
canal, whether originating there or in the blood, morbid changes have
been going on. The indication is to promote the elimination of such
material as soon and as thoroughly as possible.

Clayey stools show absence or deficiency of bile in the intestines,
whether from its non-secretion by the liver or from obstruction to its
entrance by a gall-stone in the common gall-duct. Green stools are not
uncommon in sick children. The cause of the color has been much
disputed. Probably it depends chiefly on a modification of the
bile-pigment, with some admixture of altered blood. When mercurials
have been taken sulphide of mercury may give a green color to the
discharges.

Blood, nearly or quite unmixed, coming from the bowels, may have its
origin in internal hemorrhoids, intestinal ulceration, cancer of the
rectum, intussusception, rupture of an aneurism, typhoid or yellow
fever, or vicarious menstruation.

Pus is discharged per anum in cases of dysenteric or other ulceration
of the bowel; also when an abscess occurring in any part of the
abdomen (most frequently hepatic) opens into the intestine.
Pseudo-membranous discharges, shreds or other fragments of fibrinous
material, appear sometimes in what may be called diphtheritic
dysentery. Tubular casts are occasionally seen (diarrhoea tubularis),
which, however, are most likely to consist of thickened and
accumulated mucus. Fatty discharges from the bowels are rare. Authors
report observation of them in cases of disease of the liver or
pancreas, as well as in phthisis, typhoid fever, diabetes mellitus,
cholera, and tubercular enteritis of children.

Lientery is the term applied when imperfectly changed food appears in
the stools. It shows, of course, great deficiency in the process of
digestion.

Urination affords symptoms often of extreme consequence in disease.
Suppression of urine is one of the most alarming of signs; an
approximation to it only is likely to be met with in cholera, a late
stage of scarlet fever, typhus or typhoid fever, in acute yellow
atrophy of the liver, and in advanced kidney disease. Careful
examination of the abdomen, by inspection, palpation, and percussion,
as well as by inquiry of attendants, is needful in all cases of fever
or other disorders with delirium or stupor, to ascertain the presence
or absence of retention of urine. Dysuria--_i.e._ difficult urination,
strangury--may have several causes. Cantharides, absorbed from a
blister, may produce it temporarily. The more continuous states which
cause it are--stricture of the urethra, enlargement of the prostate
gland, and calculus in the bladder. In stricture, when the patient can
pass water, it is apt to be in a twisted stream. Dribbling often
occurs when the prostate is enlarged. When a stone is present the
{165} stream may flow naturally for a time and then suddenly cease
from obstruction at the outlet of the bladder. Enuresis, incontinence
of urine, is often very troublesome in children; its diagnosis
presents no difficulty.

Diabetes properly means simply excessive flow of urine. It may be
attended by no change in the secretion except dilution of its solids
(diabetes insipidus), as in certain nervous cases or after very large
imbibition of fluids. More serious is diabetes mellitus, in which
large amounts of sugar are found in the urine.

Variations in the quantity and in the composition and solid
ingredients of the urine, as ascertained by aid of chemical analysis
and the microscope, will be fully considered in other portions in this
work.

Menstruation in the female requires scrutiny in every case of
deviation from health. Its abnormities will be elsewhere treated of.
The subject of the signs of pregnancy belongs of course to treatises
on Obstetrics.

Pain is one of the most important of the signs of disease. We must
always examine its character, location, and associations. As to
character, that of pleurisy is sharp and cutting, increased by deep
breathing or coughing. In pneumonia and in myalgia it is dull or
aching. Rheumatic joints or muscles suffer a gnawing, tearing pain. In
neuralgia it is darting, shooting, lancinating; and the last of these
expressions is often applied to the pains of cancer. Griping pains
occur in colic, and bearing-down pains in dysentery, as well as in the
second stage of labor. Besides these varieties we have the pulsating
pain of an acute external inflammation, as of the hand, especially
before suppuration has occurred; the burning and smarting of
erysipelas; and the stinging, nettling sensations (formication) of
urticaria.

Tenderness on pressure is significant either of local inflammation,
whose other signs are then to be discerned, or of non-inflammatory
hyperaesthesia. The origin of the latter may require careful
examination of various organs for its discovery. If pain is relieved
by pressure, we may be sure of the absence of severe acute local
inflammation.

Not infrequently the seat of disease may be at some distance from that
of pain, as in the familiar instances of pain at the top of the head
in uterine derangement; in the glans penis from calculus in the
bladder; in the knee from hip-joint disease; under the shoulder-blade
in liver disorder; about the heart or between the shoulders from
dyspepsia.

Anaesthesia, loss of sensibility, has much value as a symptom in
neurotic affections, as paralysis, etc. Its discussion will find place
in connection with diseases of the Nervous System in other portions of
this work.

As an example of the diversified associations of pain, cephalalgia
(headache) may be mentioned as having at least the following possible
causes: congestion of the brain, neuralgia, rheumatism of the scalp,
uterine irritation, disease of the kidneys, early stage of remittent,
typhoid, or yellow fever, alcoholic intoxication, chronic disease of
the brain.

Abdominal pain may, in like manner, be traced, in different cases, to
many morbid conditions, such as flatulent colic, lead colic, neuralgia
or rheumatism of the bowels, intestinal obstruction, dysentery,
passage of a gall-stone or of a nephritic calculus through one or the
other duct {166} respectively; cancer, aneurism of the aorta, caries
of the spine; in the female, dysmenorrhoea, metralgia or
ovaralgia--_i.e._ neuralgia of the uterus or ovaries.

Similar diversity in the origins of pain might, but for want of space,
be pointed out in morbid states of the contents of the chest and of
other parts of the body.

Subjective symptoms often affect the special senses.

Taste and touch have been already referred to. Of sight we may have
photophobia, connected with exaggerated sensibility of the retina or
of the brain; muscae volitantes, specks, rings, or chains of spots
from floating semi-opaque particles in the vitreous humor; diplopia,
double vision; hemiopia, seeing only half of an object at a time;
amblyopia, indistinctness of vision of all objects.

Hearing is affected, besides all possible degrees of deafness, with
the subjective sensations of ringing, whistling, or roaring
sounds--tinnitus aurium. One form of this (as I conclude from
observation in my own ears) depends upon spasmodic vibration of the
tensor tympani or stapedius muscle. Sometimes the seat of the
sensation is in the auditory nervous apparatus proper. It has, not
seldom, a marked connection with brain-exhaustion. An attack of
Meniere's disease (labyrinthine vertigo) is often preceded by it. No
constant signification, however, can be attached to aural tinnitus.
Large doses of quinine or of salicylic acid will occasion it in many
patients.

Very briefly, deafness may be here disposed of by mentioning that, in
greater or less degree, it may be produced by accumulated wax in the
ear; obstruction of the Eustachian tube; thickness of the membrana
tympani; perforation of that membrane; mucus or pus in the middle ear;
disease of the ossicles of the ear; paralysis of the auditory nerve;
typhus or typhoid fever; excessive doses of quinine or salicylic acid.

Vertigo is chiefly of two kinds, dizziness or giddiness (swimming in
the head), and reeling vertigo, or a disposition to fall or turn to
one side or the other. Giddiness is produced by running or whirling
many times in a circle, or, in some persons, by swinging rapidly or
sailing. Reeling vertigo is mostly observed in connection with
disorder of the brain or of the labyrinth of the ear (Meniere's
disease). Dizziness, with nausea, is common as a symptom of cholaemia
(cholesteraemia of Flint) in what is popularly called a bilious
attack.

Delirium is present in many acute disorders, and not infrequently at a
late stage in pulmonary phthisis. Its special study will be taken up
in connection with the special articles upon these affections.

Coma, or stupor, is met with chiefly in the following morbid states:
severe typhus or typhoid fevers; malignant scarlet fever; small-pox;
rarely in measles; pernicious malarial fever; uraemia; apoplexy;
opiate narcotism, or that from chloral or alcoholic intoxication;
asphyxia from inhaling carbonic acid gas, ether, chloroform, etc.;
fracture of the skull with compression of the brain.

For an account of aphasia and other morbid psychological
manifestations the reader is referred to the articles on Aphasia,
Insanity, Hysteria, etc. in this work.

Physical and Instrumental Diagnosis will be treated in connection with
those diseases in which they have special importance.


{167} PROGNOSIS.

The elements of medical prognosis are essentially involved in
diagnosis. Our ability to anticipate the mode of progress, duration,
termination, and results of any case of illness depends upon our
knowledge--1, of the nature of the malady, with its tendencies toward
death, self-limitation, or indefinite continuance; 2, the soundness or
imperfection of the patient's constitution, with or without special
predispositions or the consequences of previous ailments; 3, the
present state of his system as to the performance of the general
functions, his strength, and vital resistance or persistence; 4, the
probable modifying influences of medical treatment, and also those of
situation, surroundings, and nursing--_i.e._ the care of those
attending to the patient during the absence of the physician and
having the duty of carrying out his directions.

1. As to the nature of the malady. While every sickness must be
supposed to encroach somewhat upon the vital energy of its subject,
very few diseases (leaving aside deadly poisons and surgical injuries)
are, ab initio, certainly fatal. Hydrophobia (rabies canina) has been,
until latterly, regarded as incurable, and always mortal within a few
days or a week or two. A few cases have, during the last few years,
been reported as cured, but the diagnosis of these continues to be
somewhat doubtful.

Cancer exhibits a tendency to extend its destructive malnutrition so
as to render death inevitable unless it can be removed early and
completely, or unless the morbid process can be arrested in some
manner not yet known. Remedies, such as condurango and Chian
turpentine, which furnished hope of such an effect, have, after
prolonged trial, been abandoned as not justifying the confidence of
the profession.

Tubercular phthisis was once considered to be almost necessarily a
fatal disease, although with a very indefinite period of duration.
Under improved hygienic management, with mild palliatives and
recuperative medication, a not inconsiderable minority of cases now
end in recovery. This term may be properly applied when, with
cicatrization of a cavity or cavities in the lungs, no more tubercle
is deposited and lung-substance enough is left for good respiration,
even although the structurally changed portions of pulmonary tissue do
not undergo entire repair.

Tubercular meningitis is a nearly always incurable affection. Yet a
few instances of lasting recovery have been reported where the
diagnosis was as certain as it can be in that disease in the absence
of post-mortem examination. A child attended by myself, in whom the
symptoms had been of the most unfavorable kind, became apparently
quite well, and continued so for a month. Then it was attacked
suddenly with convulsions, which were almost unremitting until it died
within a day or two.

Gangrene of the lung is very seldom recovered from, but, unless the
diagnosis from examination of putrescent sputa has been at fault,
there have been cases in which, with the limited destruction of the
affected lung, it was not fatal.

Pseudo-membranous croup destroys life in the majority, but not in
nearly all the cases of its occurrence. It is most likely to end in
death when distinctly a part of an attack of epidemic or endemic
diphtheria.

{168} Valvular heart lesions were formerly regarded as incurable, in
the sense of restoration of the normal condition and action of the
valves impaired, yet not incompatible with years of life. This
restoration certainly very seldom takes place. But the experience of
many close observers leads to caution in anticipation of necessary and
permanent disability of the heart because of murmurs, or even
functional disturbances, seeming to prove either aortic or mitral
insufficiency or stenosis.

Aneurism of the aorta is very seldom recovered from, but, besides a
variable duration, whose period can almost never be anticipated with
exactness, there appear to have been some cases of disappearance, or
at least prolonged quiescence, of the tumor and of its morbid effects.

Yellow atrophy of the liver is one of the disorders most rarely ending
otherwise than in death.

With a course altogether indefinite in time, there appears to be a
tendency to exhaust vital energy, without self-limitation, in the
different forms of organic degeneration, such as fatty heart,
Addison's disease, chronic Bright's disease, diabetes mellitus,
cirrhosis, and amyloid degeneration of the liver, etc. The same may be
said also of the different forms of cerebral and spinal sclerosis, of
pernicious anaemia, and of myxoedema.

Lastly, it is an exception to a very general rule of fatality when a
case of trichinosis, with well-marked abdominal, muscular, and general
symptoms, ends otherwise than in death within a few weeks.

Self-limitation is familiar in the natural history of typhus and
typhoid fever, relapsing fever, yellow fever, cholera, diphtheria,
whooping cough, mumps, small-pox, varicella, scarlet fever, and
measles. In the sense of a definite duration of each paroxysm
intermittent and remittent fevers are self-limited. Are they so also
in tending toward recovery, without curative treatment within a
certain time? This has been asserted, and in the case of remittent
there is evidence that spontaneous cures do sometimes happen. Some
observers aver that ague tends toward cessation of the chills after
six, eight, or ten weeks. The obstinacy of the attacks in many
instances under anti-periodic medication seems to make it probable
that spontaneous recovery from intermittent hardly belongs to the
typical natural history of the disease.

Whether the term self-limited can or cannot with propriety be applied
to pneumonia and other acute inflammations, as pericarditis, etc., has
been a mooted question. If it be so, it appears to the writer to be
true in a different meaning of the word self-limitation from that in
which it is applied to variola or typhoid fever. Yet some nosologists
deny this distinction, and regard pneumonia as strictly a lung fever.
Some of the facts supporting this view belong to the history of
pneumonia as complicating malarial fever; _e.g._ in the winter fever
of some parts of our Southern States. It must be admitted, however,
that the inflammatory process, though morbid, is generally eliminative
or corrective of a disturbing cause which produced it, and, unless
that cause is continued or repeated in action, a limitation belongs to
the succession of stages, ending either in resolution or in adhesions,
serous accumulation, suppuration, or gangrene.

2. It is not necessary to dwell here upon the significance in
prognosis of the patient's original constitution and hereditary or
acquired {169} predispositions, or on that of results left by previous
attacks of illness. These are all obviously of importance. In a member
of a family predisposed to consumption a bronchial attack following
exposure may be much more dangerous than in others. So also a cause of
mental agitation may produce insanity in a person who inherits a
tendency thereto or who has before had an attack of mental
derangement, while it would be innocuous to another who has no such
proclivity. A second or third attack of delirium tremens is much more
dangerous to life than a first attack. On the other hand, if yellow
fever occurs at all in a patient who has before had it, the course of
the disease is apt to be milder than usual. The most striking example
of the influence of previous disease is seen in the comparative
mildness of varioloid--_i.e._ small-pox modified by the system having
been placed under the action of the vaccine virus.

3. Most important of all data in prognosis are, in most cases, the
indications of the present state of the patient's system as to the
performance of the organic functions, his sum of energy, and vital
resistance and persistence. Especially must these indications be
regarded comparatively; that is, ascertaining whether, in a period of
weeks, days, or, sometimes hours (in malignant cholera even of
minutes), the patient's general condition has been and is gaining or
losing in the evidences of strength and healthy function of the great
organs.

Every student of clinical medicine must become acquainted, as soon as
possible, at the bedside, with these tokens and evidences, which make
almost the alphabet of practice: What is a good, a doubtful, and a bad
pulse? How does a patient breathe when moribund from simple
exhaustion, and how does such respiration differ from the toil and
struggle of asthma or the stertor of narcotism? Why does a glance
suffice to make known to a surgeon the state of collapse after a
railroad accident, or to a physician that of cholera or pernicious
intermittent? What is the impression given to the finger upon the skin
by intense fever, and what by the relaxation which precedes death?
These and many other such questions are to be answered fully to each
student only by the use of his own senses, with such interpretation as
is to be obtained by the careful comparison of cases, with the aid of
books and didactic instruction.

To a well-trained eye and hand a look and a touch will often suffice
to make known the commencement of convalescence or of the precipitous
decline toward death. Yet a wise physician will be very cautious in
acting upon even seemingly obvious prognostications. Changes may be
going on in important organs whose effects have hardly yet begun to
show themselves, and which may after a while materially alter the
aspect of the case. Particularly near the beginning of an attack of
enthetic disease, such as scarlet fever, small-pox, typhus or typhoid
fever, the physician should beware of too confidently forecasting the
progress of the case for better or for worse. In nothing, probably, is
the prudence of a practitioner more often or more severely tested than
in his answers to inquiries made concerning prognosis.

4. Anticipation of the modifying action of remedies is undoubtedly a
proper factor in our estimate of the probable result of any case of
illness. Few diseases, however, are as yet so subject to control by
specific medication as to allow certainty in such expectations. In a
first attack of ague we may look with much confidence toward the
speedy cure of our {170} patient under quinia. In one who has had
chills all winter even this confidence may need qualification. A
sufferer with syphilitic rheumatism may generally be promised relief
under the use of iodide of potassium, or one afflicted with scabies
under the application of sulphur ointment. We seldom have misgivings
about our ability to give relief in colic, constipation, or diarrhoea.
Yet the first two of these may prove to be symptoms of intestinal
obstruction resisting treatment, and the last may depend upon chronic
ulceration of the bowel, giving it unexpected continuance. In all such
instances careful and (when practicable) accurate diagnosis must
precede prognosis; our estimate of the action of remedies becomes then
a secondary, although often a valuable, part of the calculation of the
probabilities of the case.

Prognosis in particular diseases involves the consideration not only
of those signs of the general vital condition to which we have just
been giving attention, but also of such as are more or less peculiar
to each disorder. To a certain extent these signs may be grouped. We
may refer to good and bad signs in pulmonary, cardiac, intestinal,
renal, cerebral, and febrile affections respectively. Still, there
will be for each malady, if it really has a distinctive character,
some tokens which experience shows to be specially indicative of
favorable or unfavorable progress and results.

Let us notice some of these as examples.

In pneumonia the best signs are the lowering of a high temperature,
reduction of the number of respirations to 20 or 25 in the minute,
expectoration of sputa less and less tinged with red or brown, and
gradual reduction of the region of dulness on percussion. Worst, in
the same disease, are an axillary temperature over 106 degrees,
respirations 40 or more per minute, with delirium, and expectoration
becoming more abundant, grayish, and purulent; also with continued
dulness on percussion and abundant mucous rales on auscultation.

In croup the best sign is, after a hoarse, dry, barking cough and
dyspnoea, a soft, liquid rale, heard in the larynx and trachea during
respiration or coughing. Worst, in croup, is a steadily or
paroxysmally increasing difficulty of breathing, with a dry hissing or
whistling sound of respiration and cough succeeding the barking sounds
of the earlier stage.

In phthisis pulmonalis among the best signs are the patient's
increasing in weight, coughing and expectorating less, ceasing to have
hectic and night sweats. These may give renewed hope, even before much
change is discernible in the physical signs. Of bad omen are intense
hectic fever, incessant cough with abundant nummular sputa, copious
perspirations, diarrhoea, breathing growing shorter and shorter, and
extreme emaciation and debility.

In all organic affections of the heart an extremely rapid and
irregular pulse, with orthopnoea and increasing anasarca, and
especially the Cheyne-Stokes respiration (described under DIAGNOSIS),
must cause unfavorable expectations.

In obstruction of the bowels the best of all symptoms is, usually, of
course, a copious fecal evacuation. Yet a few cases have occurred in
which a very large evacuation, delayed by obstruction for a week or
two, has been almost immediately followed by collapse and death. The
worst signs in cases of obstruction are (besides long-unyielding
constipation) {171} stercoraceous vomiting, a small, rapid pulse, and
increasing coldness and clamminess of the surface of the body.

In cholera infantum the best signs are cessation of vomiting and
purging, the discharges growing more nearly natural, the face becoming
less shrunken in aspect, sleep taking the place of coma vigil or
waking apathy, and water or milk, when taken, remaining on the
stomach. Worst, in the same disease, are incessant rejection of
everything swallowed, watery passages from the bowels every half hour
or hour, shrinking of the face and body to skin and bone, with an
apathetic expression of the open or half-open eyes, the latter rolling
often from side to side.

In epidemic cholera good signs are the arrest of vomiting and of
rice-water discharges from the bowels, rapid movement of the blood in
the veins after removal of momentary pressure, return of natural color
and warmth to the skin, with filling up of the pulse at the wrist. Bad
signs in cholera are shrinking of the cheeks and of the flesh upon the
hands, deepening ashiness or blueness of the skin, coldness and
clamminess to the touch, dyspnoea, loss of pulse, incessant vomiting
and purging of rice-water stools, constant cramps of the limbs, and
suppression of urine.

In acute cerebral meningitis good signs are lessened temperature of
the head, quiet sleep without stertor, disappearance of delirium, more
natural pulse, and attention to surrounding objects, without
disquietude. Bad signs in the same disease are deep stupor,
strabismus, convulsions, paralysis, involuntary defecation and
urination.

In typhus fever good signs are the pulse becoming slower and fuller,
the skin less hot, more soft and moist, the tongue moist and clean,
the face losing its dusky flush, and consciousness returning instead
of muttering delirium.[40] Bad, in the same fever, are deepening of
the flush of the countenance, profound stupor, rapid and feeble pulse,
lying on the back and sinking down toward the foot of the bed, with
suppression of urine.

[Footnote 40: Incidentally, it may be mentioned that the return of the
pulse to its normal rate is often considerably delayed in
convalescence from typhus and typhoid fevers and other protracted
diseases. If, then, the temperature is not above 99 degrees F., and is
stable from morning to night, the tongue is clean and moist, and
appetite begins to appear, we need not be alarmed, although the pulse
continues as high as 90 or 100 per minute, in a case attended by
positive debility.]

In typhoid fever many of the good and bad signs are the same as in
typhus, belonging to closely similar general conditions. But in
typhoid fever we observe also as favorable signs the lessening of
tympanites, more nearly natural fecal stools, and the absence of
tenderness in any part of the abdomen. As unfavorable, increase of
tympanites and diarrhoea, sometimes large hemorrhages from the bowels;
worst of all, at a late stage, sudden increase of abdominal
distension, with dulness on percussion, coldness of the skin, great
rapidity and feebleness of the pulse following perforation of the
bowel, resulting usually in fatal peritonitis.

In scarlet fever, measles, and small-pox it is a favorable sign for
the eruption to come out well at the usual time; its sudden recession
threatens malignancy. In small-pox a confluent eruption marks a
dangerous case, and so does the occurrence of distinct pustules in the
throat. Early in scarlet fever stupor is very threatening, though not
necessarily mortal. Late in the same disease bloody urine, or, worse
yet, suppression of urine, may well cause alarm.

In all children's diseases the early occurrence of convulsions shows a
{172} severe but not always a dangerous attack. The late occurrence of
convulsions is commonly much more serious in its significance.[41]
Convulsions are always of vastly less importance, prognostically, in
children than in adolescents or adults. Yet they are always serious
signs. While recovered from in the large majority of cases, they may
at any time be fatal.

[Footnote 41: Yet I saw a case of acute cerebro-meningitis, in a girl
ten years of age, in which a violent convulsion occurred on about the
sixth day of the disease, and was followed by convalescence.]

These enumerations, selected as examples merely, might be much farther
extended but that the special prognosis of each disease will be fully
set forth in the several articles upon them in the body of this work.
Those now given may suffice for the illustration of the method and
general principles by which the physician must be guided in his
anticipation of the progress and result of cases of disease. The
caution may be repeated, to observe great care in forming a conclusion
in regard to prognosis in every instance, and still more in expressing
it, unless in the presence of very clear and positive evidence.



{173}

HYGIENE.

BY JOHN S. BILLINGS, M.D.


The purpose of this paper is to indicate some of the ways in which
hygiene, both private and public, is connected with the duties of the
general practitioner, and to give some information as to modern
methods of investigation and work in preventive medicine.

While the business of the physician is more especially the care of the
sick with reference to the cure of disease, or, where that is beyond
his power, as is too frequently the case, to relieve suffering and
secure temporary ease for his patient, he is nevertheless often called
upon to answer questions as to the causes of disease, and the best
means of avoiding or destroying these causes. Not only does diagnosis
often turn upon considerations of etiology, but a very considerable
part of the treatment of actual disease must be hygienic in the
broader sense of the word. The prescription or the surgical operation
must not only be supplemented by advice as to residence, clothing,
food, exercise, etc., but must, in many cases, be merely supplementary
to such advice, which indicates the really essential method of
treatment; and the giving this advice then becomes the most important
part of the physician's work, although not usually recognized as such
by his patients. The chief value of the prescription is, in fact,
often to methodize the mode of life of the patient and to remind him
at frequently recurring intervals of the regimen which has been
ordered with it.

The physician has also certain duties in relation to the public at
large, as well as to his individual patients, and these duties become
more numerous and important as the density of population increases, so
that in the large cities of most civilized countries he finds himself,
nolens volens, in almost daily contact with legally constituted
authorities in the shape of registrars, health officers, coroners,
etc., and is not infrequently summoned before the courts as a supposed
expert in matters connected with the public health.

Moreover, the physician who has become eminent in his profession is,
in many cases the adviser, and, so far as professional subjects are
concerned, to a great extent the guide, of those who legislate for, or
execute the laws of, not only his own city or county, but his state
and the nation; and he must to a corresponding degree be held
responsible for the position which he takes and the advice which he
gives in regard to public health matters. This is true whether his
attitude on these subjects {174} be active or passive, for his silence
will be taken to mean that there is no necessity for action or change.

The limits of this paper do not permit the presentation of proofs and
illustrations of these somewhat dogmatic assertions, but it is
believed that they will meet with general assent from medical men
without formal and detailed argument, and that it is unnecessary here
to urge the interest or importance of practical hygiene upon the
medical profession, or to enlarge upon the desirability that the
practitioner, as well as the professional sanitarian, should be
familiar with the conclusions of modern science and technology with
regard to it.

In the minds of many intelligent and thoughtful physicians there is,
no doubt, a feeling of unformulated distrust as to the real
possibilities or probabilities of improving the health and diminishing
the mortality of the community at large; and this feeling is in part
due to the exaggerated claims and emotional exhortations of some
advocates of hygiene. A careful and unprejudiced survey of what has
been accomplished by sanitary measures will, however, largely
dissipate this distrust.

The natural term of the life of man is fixed by the physiologist at
about one hundred years, which is nearly in accordance with the law
indicated by Flourens, that the period of life of an animal is about
five times that required to perfect the development of its skeleton
and unite the epiphyses with the shafts of the long bones. The actual
average duration of human life is less than half this, but there is
satisfactory evidence that it has increased in civilized countries.
The ancient estimate is expressed in David's declaration, that "the
days of a man are threescore years and ten, and if by reason of
strength they be fourscore years, yet is their strength labor and
sorrow." Kolb, a cautious and learned statistician, concluded, from
his studies, that while the maximum age reached by man has not
materially changed for many centuries, the number of persons who now
survive infancy and of those who reach a ripe old age has decidedly
increased; and this opinion is sustained by Mr. Lewis, the secretary
of the Chamber of Life Insurance of New York, who points out that
while civilization largely interferes with the laws of evolution by
survivorship, it aids by economizing the waste which occurs in its
absence. "Under natural selection, when variations in capacity arise,
thousands of them are wasted where one is secured, fixed, and
transmitted. But human society economizes much of this waste, fastens
upon and improves an immensely larger proportion of the capacities
lavishly produced by Nature, and thus concentrates forces which would
otherwise spread their operation over countless ages."[1]

[Footnote 1: "Influence of Civilization on the Duration of Life,"
_Reports Am. Pub. Health Ass'n_, N.Y., 1877, vol. iii. p. 173.]

We have, however, no record of the duration of life in ancient Greece
and Rome, and it is quite possible that it was greater than in Western
Europe during the Middle Ages, which formed a period of retrogression
in a sanitary point of view. The Jew, the Greek, and the Roman, prior
to the Christian era, were probably cleaner in person and in dwellings
than the people of the time when dirt became the odor of sanctity.

In the absence of reliable data for this country, it is impossible to
speak with certainty of the results of attempts made here to prevent
disease and death. Each sex, race, and age has its own rate of
mortality, {175} and until this rate is determined we can only guess
as to whether good work is being done or not.

We can never hope to diminish the total number of deaths which will
occur in long periods, say two hundred years, but we may rationally
try to prolong the average duration of life, to diminish infant
mortality, and to secure greater comfort and better health for
individuals and for the community at large.

The reader must remember that only a mere outline of the subject can
be presented here; the details would require several volumes, and the
tendency to specialization in this, as in other branches, is so great
that it is hardly to be expected that any one man shall have either
the theoretical or the practical knowledge necessary for covering the
entire field. There are certain things in relation to hygiene which
every physician should know; there are many other things with regard
to which it is sufficient if he knows where to find full and reliable
information when he needs it. With this preface we will pass at once
to our subject, which may be conveniently divided as follows:

    I. Causes of disease, means of discovery, and prevention.
   II. Personal hygiene in its relations to the practice of medicine.
  III. Public hygiene in its relations to physicians.


I. Causes of Disease, Means of Discovery, and Prevention.

Although the origin of disease has from the earliest times been the
subject of study by medical men, the physician has not heretofore,
usually, been called upon to investigate the causes of disease in
particular localities, until the occurrence of sickness in that
locality has called attention to the matter. The education of the
public as to the importance of sanitary work has, however, recently
made great progress, and it is now not unusual to ask the opinion of
the family physician as to the healthfulness of a given locality or
house. The question may be presented in three different ways: First.
In a given case of disease, what is the probable cause? Second. Given
the presence of a known or suspected cause of disease, what are the
best means of avoiding or destroying it? Third. In the absence of
cases of disease, to determine whether causes of disease are probably
present, and if so, what causes.

The word "cause" is here used in its widest sense, including not only
what are commonly called predisposing and exciting causes, but also
those conditions which aggravate or continue the disease. These causes
may be roughly classed as follows: Heredity; impure air; impure water;
climate; habitations; occupation; food; intemperance of various kinds;
clothing; errors in exercise; sexual errors; parasites; contagia;
expectant attention and other mental causes, including worry, etc. In
most cases two or more of these classes of causes are combined in
action for the production of a given case or outbreak of disease, and
when we refer any disease to a single factor, what is meant usually
is, not that this is the sole and exclusive cause, but that it is the
most prominent one.

Bearing this in mind, let us consider briefly some of the causes above
mentioned.

I. HEREDITY.--That the child inherits from its parents its physical
{176} type, including color, stature, physiognomy, temperament, and
certain peculiarities of structure or arrangement of internal organs,
is well known. This hereditary influence is stronger from the
immediate than from the remote ancestry, although the curious
phenomena of atavism sometimes form exceptions to this rule. The
hereditary causes of disease can be guarded against when known.
Theoretically, by preventing generation on the part of persons who are
unfit to produce offspring; practically, to a certain extent, by
taking special precautions against these causes and their effects in
the individual, particularly at those ages in which these influences
seem to have their greatest force. The most important of these
hereditary diseases are syphilis, consumption, scrofula, cancer, gout,
certain skin diseases, insanity, and criminal tendencies of various
kinds.

The physician's advice is rarely asked with regard to the propriety,
from a sanitary point of view, of a proposed marriage, nor is it often
taken when given, unless, indeed, it happens to correspond with the
wishes of the recipient; nevertheless, he is occasionally in a
position to exert influence in such a matter, and when this is the
case the following general rules may be borne in mind: 1. No marriage
should occur between persons having the same hereditary tendency to
disease; and this is especially important in marriages between
relatives. 2. A girl should not marry under the age of twenty. 3. A
person affected with hereditary or well-marked constitutional
syphilis, or having a strong consumptive taint, or tendency to mental
unsoundness, should not marry at all.

The precautions to be taken in individual cases in which there is a
known hereditary predisposition to certain diseases will probably be
indicated in the articles upon those special diseases. The most
important of these, from the sanitary point of view, are consumption
and gout, partly because of their frequency, partly because of the
undoubted power which a proper regimen, applied in time, has in
controlling them. The pain in gout has often an excellent sanitary
effect; it is an inducement to temperance much stronger than any
amount of good advice.

The influence of heredity in producing abnormities of refraction and
accommodation of the eye, and the importance of detecting these early
and giving them proper treatment, have not hitherto received, from the
general practitioner, the attention which they deserve. Children of
parents affected with astigmatism, ametropia, etc. should be carefully
examined before being placed at school, and if necessary fitted with
proper glasses.

The heredity of idiosyncrasies as to certain articles of food or
certain drugs must also be borne in mind by the physician, for,
although implicit confidence is not always to be placed in the
statement of a patient that he cannot take a certain medicine, yet a
knowledge of the facts will occasionally save the prescriber from some
awkward mistakes.

The importance of bearing in mind the family peculiarities is best
appreciated by the old family doctor who has had two or three
generations pass under his hands: he knows, for example, that in one
family he may expect brain complications, in another lung troubles,
and that what would be grave symptoms in one house are of
comparatively small import in another. Unfortunately, the greater part
of this kind of knowledge has not yet been formulated, and each
physician has to acquire it for himself; but he will find the process
of acquisition greatly facilitated if in all cases in a new family he
makes it a rule to learn something of the medical {177} history of the
parents, and he will find intelligent laymen quick to appreciate his
inquiries in this direction.

The importance of taking into account hereditary influences is well
illustrated by the care which is taken to obtain information with
regard to them in well-conducted life insurance companies. The medical
examiners of such companies have their attention specially called to
this matter, and the following extract from a manual of instructions
shows how it is regarded from a business point of view: "If
consumption is found to have occurred in the family of the applicant,
he is to be regarded not insurable under the following circumstances,
viz.:

                                                       YEARS OF AGE.
  If in both parents, not insurable until . . . . . . . . .  40
  If in one parent, not insurable until . . . . . . . . . .  30
    (Except for ten-year endowments, then 20 years.)
  If in two members (not parents) . . . . . . . . . . . . .  35
  If in one member (brother or sister)  . . . . . . . . . .  20
    (Except for ten-year endowments, when peculiarly favorable.)"

If apoplexy, paralysis, or heart disease is found to have occurred in
any two members of the applicant's family, he is to be regarded as
insurable only upon the endowment plan, the term of insurance to
expire prior to his reaching the age of fifty years. If insanity shall
have so occurred (in two members), a provisionary clause is essential,
and is attached to the policy by the company.

II. IMPURE AIR.--The dangers of impure air, water, and food depend
largely upon the fact that through these media may be introduced into
the body particles of organic matter, living or dead, which tend to
produce disease in the recipient. The parasites are types of this mode
of disease-production, and these blend with the contagia of the
specific diseases in such a way that it is not easy to draw the
distinction in all cases. There are also certain poisonous gases and
inorganic compounds which may occasionally be present in air or water
to such an extent as to produce disease; but as a rule the gaseous
impurities of the air are offensive to the smell rather than
dangerous, as will be seen when we come to consider the effluvium
nuisances.

The subject of ventilation, for the purpose of procuring an adequate
supply of pure air, is one of so much importance, and one upon which
the physician is so liable to be called for practical advice, that it
seems proper to state briefly the general principles which should
govern investigations into, or recommendations upon, this subject.

The impurities of air which are to be disposed of by ventilation are
for the most part derived from the human body, chiefly from
respiration, and these only will be considered here. In some cases it
is necessary to make special provision for the products of combustion
from gas, etc., but as a rule this is rather for the purpose of
regulation of temperature than anything else. The impurities of air
due to the presence of human beings consist mainly of carbonic acid,
ammonia, sulphuretted hydrogen, and sulphide of ammonium, and of
various organic compounds, mostly in the form of minute particles of
organic matter of uncertain structure, but extremely prone to
decomposition. It is usual to estimate the degree of impurity by the
amount of carbonic acid present, and this leads many persons to
suppose that the carbonic acid is in itself the chief and most
dangerous impurity. This gas is, however, not perceptible to the
senses, {178} nor is it injurious to health, unless present in much
greater proportion than that in which it will be found in the most
crowded habitations or assembly-rooms. Its importance in questions of
ventilation depends upon the fact that its increase in a room beyond
the amount present in the outer air may usually be taken to be in
direct proportion to the amount of the really dangerous and offensive
impurities present, and that the amount of carbonic acid can be
ascertained by chemical tests with comparative ease and rapidity;
which is not the case with regard to the organic matter. The carbonic
acid is therefore taken as the measure of the impurity, although it is
not itself the impurity of which we are most anxious to be free.

To decide as to whether a room is well ventilated or not, some
standard of permissible impurity must be fixed, and this standard is
now usually taken to be, in a room occupied by human beings, that
condition of air which produces in a person having a normal sense of
smell, and who enters from the fresh air, a faint sensation of an odor
very slightly musty and unpleasant. Upon testing the air of such a
room, it will be found that the amount of carbonic acid impurity
present--that is, the excess of this acid over the amount in the
external air--will be between 2 and 3 parts in 10,000.

As the amount of carbonic acid in normal air varies from 2 to 5 parts
in 10,000 in different places, and in the same place at different
times, it is better to look to the carbonic acid impurity as above
defined rather than to the total amount of the acid found present, if
strict accuracy is desired; but usually the statement of Dr. Parkes is
correct, that the organic impurity of the air is not perceptible to
the senses until the total carbonic acid rises to the proportion of 6
parts in 10,000 volumes. When the carbonic acid reaches 9 parts in
10,000 the air is close, and when it exceeds 1 part in 1000 the air is
usually decidedly unpleasant. If we take 2 parts in 10,000 as the
permissible maximum of carbonic acid impurity, it follows that the
amount of fresh air which must be supplied and thoroughly distributed
for each person per hour is 3000 cubic feet. If 3 parts per 10,000 be
taken as the permissible maximum (which is the standard of
Pettenkofer), the amount of air per head per hour must be 2000 cubic
feet. While it is impossible, as Dr. Parkes remarks, to show by direct
evidence that the impurity indicated by 7, 8, or even 10, parts of
carbonic acid per 10,000 is injurious to health, it is advisable to
accept his standard, because it is a simple one, and can be
practically applied without special apparatus or technical skill, and
because there is evidence of the injury to health which continued
exposure to air impure, by this standard, ultimately produces.

Keeping this standard in view, the physician may be called on for an
opinion as to whether the ventilation of a given building is
satisfactory or as to the merits of a proposed plan for ventilation.
The first is a question of fact: What are the effects produced upon
the inmates? Are there unpleasant odors in the building or not? What
percentage of carbonic impurity is present? What is the number of
cubic feet of air per head that is introduced and removed per hour?
And what is the character of the fresh-air supply as to purity? Does
it come from the cellar, or from other rooms, or from a foul area?
Air-currents can usually be best investigated by the fumes of nascent
muriate of ammonia produced by {179} exposing a cylinder of common
blotting-paper, moistened with dilute hydrochloric acid, to the vapors
coming from a crumpled fragment of the same paper moistened with
common aqua ammonia and placed within the cylinder. The process for
carbonic acid determination is simple, and can be learned in three
hours in a laboratory under a skilful teacher. It does not seem worth
while to describe it here. The determination of the amount of air
passing through a given register, flue, or chimney in a given time is
to be made by the use of an anemometer, an instrument which registers
the velocity of the current of air passing through it.

In judging of the merits of a plan of ventilation the following points
should be remembered: The defect in most plans for ventilation is in
the air-supply. Many people suppose that they have made all necessary
provision for ventilation if they have put in tubes or openings for
the escape of foul air, forgetting that these outlets will have no
effect if corresponding inlets are not provided. Examine, first of
all, therefore, the ducts, flues, and openings proposed for the
fresh-air supply, with reference to their size and position and the
amount of air to be furnished by them. These will almost invariably be
found to be too small. The proper size of flues and registers for a
given room is ascertained by dividing the number of cubic feet of air
to be supplied per second by the velocity in feet per second which the
air is to have in the flue or opening, bearing in mind that it is much
better that these flues and registers shall be too large than too
small, since it is easy to reduce their capacity, but, in most cases,
impossible to increase it. When the fresh-air register is so situated
that the current of air from it is liable to strike upon the person of
an occupant of the room, the velocity of this current should not
exceed 1-1/2 feet per second if unpleasant draughts are to be avoided;
and it will usually be found best that the velocity of the air in the
flue shall not exceed 6 feet per second, except in the case of very
large flues, where the element of friction becomes of comparatively
small importance. In the great majority of cases the amount of air to
be supplied depends upon the number of persons, and not on the cubic
space; but in exceptional instances, where the amount of cubic space
is very large in proportion to the number of persons, and the heating
is effected by warm air, it may require more air to keep the room at a
comfortable temperature than is necessary for the supply of the
occupants. The cubic space is also relatively much more important in
rooms which are to be occupied but a short time continuously, and can
then be thoroughly aired, than it is in rooms constantly occupied.

The methods of calculation can be best illustrated by one or two
examples. What should be the number and size of flues and registers
for fresh-air supply for a hospital ward to contain 24 beds, the ward
being a rectangular pavilion with windows on opposite sides? In this
case the room is constantly occupied, and the supply of air should be
1 cubic foot per head per second, or, in all, 24 cubic feet per
second. The velocity of current at the registers should not exceed 3
feet per second--better only 2. This will require from 8 to 12 square
feet of clear opening in the registers. If we allow four on each side
of the room, each register must have at least 1 square foot of clear
opening. The velocity of the air in the flues supplying these
registers should not exceed 4 feet per second, and therefore the area
of each flue should be about 9 by 12 {180} inches. Suppose the same
question be asked with regard to a school-room to contain 48 pupils.
In this case the room will not be occupied more than two hours at a
time. The air-supply desirable may be put down at 35 cubic feet per
head per minute, or 28 cubic feet per second for the whole. The
velocity in the flues may be put, as before, at 4 feet per second;
hence we need 7 square feet area of flue, or seven flues, each having
1 square foot of area. It is safe to say that there are not twenty
school-houses in the United States which have fresh-air flues of
sufficient area; the deficiency is made up, for the most part, by
leakage of the outer air through cracks around windows and directly
through the wall, and also by the passage of air from the central hall
into the room, this last air coming from the cellar or basement.

The velocity of the air at the foul-air registers and in the foul-air
ducts may be greater than in the fresh-air flues, since there is no
danger of its causing draughts, and hence there is no truth in the
common notion that the outlets should be larger than the inlets to
allow for the expansion of heated air. It is important that the
velocity of the current in the outlet shaft or chimney should be at
least 8 feet per second at the point where it escapes into the outer
air; and if the outlets be too large for the inlets, the result may be
that some of the foul-air flues will work backward and become inlets.
The plan of making everything a little larger than is necessary is not
a safe one as regards chimney-flues and outlet shafts.

The merits of a plan of ventilation depend not only on the amount of
air introduced, but on its distribution. The test for distribution is
chemical analysis of samples taken in different parts of the room and
at different levels. A very good idea of the direction taken by the
incoming air can also be obtained by the use of fumes of nascent
muriate of ammonia, as above described. In considering the
distribution which will probably take place in a given plan, care
should be taken not to fall into the common error of supposing that
because pure carbonic acid gas is heavier than air, therefore the
carbonic acid derived from respiration sinks to the floor, and that
special provision should be made to remove it at that point. The law
of the diffusion of gases effectually prevents this separation and
sinking of the carbonic acid from the mixture of gases expired, and it
will be found to be present in about equal proportions in all parts of
an inhabited room.

The methods of introducing and distributing fresh air depend to a
great extent upon the methods of heating employed; and it is necessary
to remember that while good ventilation is a very desirable thing,
satisfactory heating is, in cold weather, still more desirable, and
must be attained even if the ventilation is interfered with for that
purpose. The principal difficulty in the way of securing good
ventilation is its cost. In a cold climate satisfactory heating, good
ventilation, and cheapness are not compatible; it is comparatively
easy to obtain any two of them, but impossible to have the three
together. This fact should be fully understood and realized by the
physician, for its comprehension will save much time in considering
the merits of various patent ventilators and ventilating appliances,
which, according to their inventors, produce good ventilation at no
expense beyond that of the original cost of the apparatus; which is
practically about the same as a claim to have discovered perpetual
motion. Patent ventilators are usually cowls to be placed upon the top
of outlet {181} flues. I know of none which are superior to the common
Emerson Ventilator, on which there is now no patent. In cold weather
the air must be warmed to secure comfort; it must be changed to secure
ventilation. The changing of the air carries off heat, the loss of
which must be supplied by fuel, which fuel costs money. The greater
the ventilation, the more rapid the change and the more heat required.
It is therefore quite possible to judge somewhat of the merits of a
heating and ventilating apparatus--for example, of a
school-house--from the amount of fuel consumed; but the conclusion
will be precisely the reverse of that drawn by the average trustee,
since it will be, that within certain limits the less fuel required
the less satisfactory the apparatus.

The evil effects of insufficient ventilation, although very certain
and very serious, are not immediate, or such as to attract attention
at first, except in very aggravated cases with excessive
over-crowding. The power of the organism to adjust itself to
surrounding circumstances is very great, and perhaps as great in
regard to the endurance of foul air as anything else. Yet this power
is greater in seeming than in reality, for at last such air produces
disease and shortens life. Its effects are manifested in diseases of
the respiratory organs, acute and chronic, and it is now generally
admitted that the undue prevalence of phthisis in troops is due to the
foul air of the barrack-rooms.

Some persons are much more susceptible than others to the effects of
impure air, and will suffer from headache, languor, loss of appetite,
etc. where others would experience little inconvenience. Children thus
susceptible dread the school-room as ordinarily constructed and
ventilated, and their discomfort should be taken into account and
guarded against.

Thus far, reference has been made only to those impurities of air due
to respiration and lights; in other words, the necessary impurities
found in human habitations. The impurities due to sewer gases will be
referred to hereafter; they should be prevented absolutely, and not
provided for by ventilation. One of the most difficult problems
presented to the physician is to determine whether the effluvia from a
given locality are injurious to health, and if so, to what extent.
These effluvia may be due to certain occupations or manufactures, or
they may result from the disposal of excreta, from obstructed drainage
giving rise to swamps and the collection of decaying organic matter,
and in other ways. The best definition of the term "injurious to
health" in this connection is perhaps that suggested by Dr.
Ballard--_i.e._ that exposure to the offensive effluvia causes bodily
discomfort or other functional disturbance, continuing or recurring as
the exposure continues or recurs, and tending by continuance or
repetition to create an appreciable impairment of general health and
strength, to render those exposed more liable than others to attacks
of disease, and more apt to suffer severely when attacked, and, in the
more serious forms, to the direct production of the disease and the
shortening of life.

The group of symptoms due to offensive effluvia is, as Dr. Ballard
remarks, a tolerably constant one, and consists of loss of appetite,
nausea, headache, giddiness, faintness, and a general sense of
depression, with, in some cases, vomiting and diarrhoea. But it is
usually impossible to prove by statistics that these phenomena are due
to a given effluvium complained of, for those who suffer from it are
usually exposed to other causes of ill-health, such as poverty,
overcrowding, collection of filth, etc.; and, on the {182} other hand,
many of those exposed to the effluvium seem to suffer very little, if
at all, from their surroundings. And so true is this, that in the
carefully prepared report upon effluvium nuisances recently issued by
Dr. Ballard,[2] it will be found that as a rule no attempt is made to
prove that the effluvia from any particular branch of industry are
injurious to health; the test practically applied is that they produce
offensive odors.

[Footnote 2: _Report in respect of the Inquiry as to Effluvium
Nuisances arising in connection with various Manufacturing and other
branches of Industry_. By Dr. Ballard, London. Her Majesty's
Stationery Office, 1882, 8vo.]

The legal view of this subject is given in the various decisions as to
what should be considered a nuisance, the essence of which is the use
of one's own property in such a way as to inflict damage upon, and
injure the rights of, another. If a man collects on his own premises,
for his own use, any material, such as water or filth, he is bound to
retain it within his own premises or to let none of it escape in such
a way as to damage others; and this holds good as regards gases,
vapors, and odors. The decision of Mansfield, in the case of Rex _vs._
White, is often quoted approvingly by jurists, viz.: "It is not
necessary that the smell be unwholesome; it is enough if it renders
the enjoyment of life uncomfortable." But, practically, the question
as to whether the discomfort produced is sufficient to produce
ill-health will be the one upon which the physician is called to give
evidence, and the one also upon which he will find it most difficult
to obtain data sufficient to enable him to form a positive opinion.

III. IMPURE WATER.--Of all the various preventable or removable causes
of disease to which the attention of the physician engaged in practice
in the small towns and rural districts is directed, it will usually be
found that the water-supply is the most important, because it is in
these localities that it is most liable to become contaminated in such
a way as to produce sickness.

All water used for drinking purposes is impure in the chemical sense,
since it contains some inorganic matters or salts, and in most cases
organic matter also. It is difficult to define precisely what should
be considered an impure water in a sanitary sense, and the best we can
do is to indicate probabilities in the absence of positive evidence of
the production of disease by the suspected water. So far as inorganic
impurities are concerned, the most important, from the sanitary point
of view, are the salts of lead, magnesia, and lime, but in this
country these are so rarely the cause of disease that they hardly
require special notice. The physician should, however, bear in mind
possibilities of lead-poisoning in some obscure cases which he will
meet.

The diseases due to impure water are certain specific fevers,
diarrhoeal diseases, and some affections due to parasites which find
entrance to the body through this medium. The water-supply is to be
suspected in case of prevalence of diarrhoeal disease in a community,
and especially if the outbreak be sudden and affect a number of
persons and families. Sudden outbreaks of cholera, typhoid fever, or
malarial fever, confined to a limited locality, should lead to careful
examination of the water-supply. The impurity in water which causes
these diseases is supposed to be either organic or the product of
organic life, and at present the prevailing opinion is that the really
dangerous impurities consist of minute living organisms or {183}
germs. It is usual to estimate the impurity of water by the amount of
organic matter present, but it is evident that this alone can give no
positive information, since by this standard milk and soup would be
very dangerous. Much depends upon the character of the organic matter,
whether it is derived from the animal or vegetable kingdom--whether it
is in a state of fermentation or putrefaction, etc. etc.; but the
presence of specific germs in it is the most important part of all,
and at the same time the most difficult to ascertain. Nitrogenous
organic matter in a state of decomposition is dangerous, yet it does
not always produce disease, even when ingested in comparatively large
quantity, as in case of "high" game or tainted meat; and it is easy to
find instances where water strongly polluted with sewage has been used
for a considerable period without producing marked ill effects. It is,
however, so extremely probable as to be for practical purposes
certain, that water contaminated with the discharges from persons
suffering from certain diseases will produce similar diseases in those
who drink it, and there is also enough evidence that water containing
filth of various kinds either produces or promotes disease to warrant
much more attention to this subject than has heretofore been bestowed
upon it.

The chemical examination of a suspected water is by no means a simple
process, and in most cases had better be referred to an expert in such
matters. It is highly desirable, however, that the physician should
have sufficient technical knowledge to be able to make a rough
analysis at least, if for no other reason than that he may be able to
appreciate the results reported by the chemist. As a rule, when a
water is so polluted with decomposing organic matter as to be
positively dangerous it will have an unpleasant odor, which is best
developed by half filling a quart bottle with the water to be examined
and shaking it thoroughly. The so-called simple and ready methods
which are from time to time advocated in the newspapers, such as the
addition of sugar to the suspected water and allowing fermentation to
take place, the use of tannin as a precipitant, or the decolorization
of a solution of potassium permanganate, are really of very little
value and should not be relied upon. In the hands of an expert the
best simple method of determining the quality of a water is by
evaporation of a known quantity and the ignition of the solid residue.
From the amount of the total residue, the quantity left after
ignition, the amount of blackening produced, and the odor, a very fair
opinion can be formed as to the amount of organic matter present, and
whether it is of animal or vegetable origin.

It is not within the province of this paper to describe the methods
used by chemists in water analysis, of which the principal are known
as the Franklin and Armstrong, the Wanklyn, and the permanganate
methods. A careful examination of these methods has recently been made
under the direction of the National Board of Health, and a preliminary
note of the results, prepared by Professor Mallet, has been published
in the _Bulletin_. From this it appears that the chief value of
chemical analysis is, first, the verification of gross pollution,
which will usually be detected by the appearance and smell of the
water; and, second, in periodical examination of a water-supply to
detect changes from the normal or usual character of the water, which
may be taken to have a certain local standard of purity. Special
importance is attached to the careful determination of {184} nitrates
and nitrites in water to be used for drinking, these being the results
of oxidation of organic matters, and therefore giving evidence of
previous contamination.

Prof. Mallet concludes that "there are no sound grounds on which to
establish such general standards of purity as have been proposed,
looking to exact amounts of organic carbon or nitrogen, albuminoid
ammonia, oxygen of permanganate consumed, etc., as permissible or not.
Distinctions drawn by the application of such standards are arbitrary
and may be misleading." While this is perfectly true, considered from
the standpoint of scientific precision, it does not sufficiently take
into account the value of probabilities in these matters, considered
as motives to action. It is perfectly true that there can be no fixed
standard--that a water which the chemist would report as relatively
pure might be much more apt to produce disease than one which he would
pronounce impure--but it is nevertheless true that from the results of
chemical analysis, taken in connection with evidence as to the source
and history of the water, an opinion can be formed as to the danger
from its use which is sufficiently reliable to be acted upon in the
absence of positive evidence, such as the production of disease.

In many cases the matter must be doubtful, and Prof. Mallet truly says
that it will not do in all such cases to forbid the use of the water,
for it often happens that this should not be done unless it is
absolutely necessary; but there are many other cases in which there is
very little doubt, and where action should be governed by the
probabilities.

The microscopical examination of suspected waters sometimes gives
decided indication as to the nature of the impurities; and it may be
that hereafter, in connection with physiological tests, it will become
of even more importance than the chemical. To determine the presence
of organisms in a sample of water the best method known at present is
to kill and coagulate them by means of osmic acid or chloride of
platinum, and allow them to subside. This method is of course
inapplicable if it be desired to use them for either culture- or
inoculation-tests.

Chemists have no uniform system of reporting the results of their
analyses, some using grains per gallon, U.S. or Imperial as may be,
and others parts per hundred thousand or per million of the water. It
is therefore difficult to appreciate the value of the figures as given
by them. The following, in parts per 100,000, will enable the
practitioner to form a general estimate of the character of analytical
reports; but the opinion in individual cases is so modified by the
coincident amounts of chlorine, ammonia, nitrous and nitric acids,
that the experienced sanitarian only is qualified to put on the
results an estimate which shall be in accordance with our present
knowledge of such matter:

  _Upland Surface-Waters_.
                          Allowable.    Doubtful.      Impure.
  Total organic elements    to .4      .4   to .6      Over .6
  Oxygen required           to .3      .3   to .4        "  .4
  Albuminoid ammonia        to .015    .015 to .025      "  .025

  _All Other Waters_.
  Total organic elements    to .2      .2   to .4      Over .4
  Oxygen required           to .15     .15  to .2        "  .2
  Albuminoid ammonia        to .010    .010 to .015      "  .015

{185} In connection with impure water should be mentioned impure ice.
Ice is purer than the water from which it forms, but if cut on a foul
pond it will itself be foul, and the vitality of some microscopic
organisms is not destroyed by their being frozen, as is shown by the
fact that samples from the centre of blocks of ice will inoculate
sterilized infusions with the germs of putrefaction, precisely as the
water of which the ice is composed would have done before it was
frozen. Disease has been traced to impure ice, and it may be that it
is more frequently due to this cause than has heretofore been
supposed; at all events, it is well to bear the possibility in mind.

The subject of impure water will be further considered in speaking of
habitations.

IV. CLIMATE.--The literature of the effects of different climates upon
the human body is very extensive, following the general rule that the
less positive or precise knowledge there is upon a given subject the
more will be written about it. Of all animals, man seems to adapt
himself most readily to the extremes of climate; and, although it is
commonly supposed that a tropical climate is injurious to those coming
from cooler regions, yet it has been found that where he takes the
same precautions to ensure cleanliness, pure water and air, and proper
food, the European does not have a higher rate of mortality in Algeria
or in the East or West Indies than he does at home, if the effects of
cholera and yellow fever be excepted.

Dr. Parkes defines the effect of climate upon the human body to be
"the sum of the influences which are connected with the solar
agencies, the soil, the air, or the water of a place;" in other words,
he makes it nearly equivalent to the locality or the environment. By
"climate" we understand, commonly, the sum of meteorological
influences, the most important of which, as regards health, are
temperature, humidity, and wind. The effects of temperature in
producing disease are often confounded with the effects of change of
temperature, which last is perhaps the more important of the two, and
should be specially borne in mind in advising climato-therapy for
chronic or wasting diseases.

The influence of climate in causing disease, although well known for
over two thousand years, has not led to much effort to avoid or
prevent effects which are accepted as inevitable by the great
majority. It is true that in the effort to secure physical comfort by
houses, clothing, artificial heat, and the like, much hygienic work
has been done, and the steadily increasing tendency on the part of all
who can afford it to seek rest and comfort at the seaside or in the
mountains during hot weather is no doubt due, in part, to the fact
that experience has shown that the money expended in thus securing
health and strength is a good investment. It is unfortunate that
"health resorts," so called, do not always prove to be such: they
become fashionable, overcrowded; the arrangements for the disposal of
excreta are cheap makeshifts, leading to soil- and water-pollution,
until finally an epidemic of diarrhoea or typhoid fever occurs, with
the usual results.

The consideration of climate as a therapeutic agent belongs with the
articles relating to the several diseases to which it is applicable.
The great desideratum wherewith to place this subject upon a
scientific and practical basis is a system of reliable returns of the
deaths, and if possible of {186} certain diseases, throughout the
country, and especially at those points most in vogue as health
resorts.

V. HABITATIONS.--That a man's health depends very much on the
character, condition, and location of his dwelling-place is now so
generally admitted that in many cases where a physician is called in
he will be asked whether he thinks the disease has been caused by any
peculiarity about the house or the bedroom of the patient. And a
careful examination will usually discover in one of them several evils
to be remedied, although their connection with the case in hand may be
very doubtful. There are very few homes properly constructed from a
sanitary point of view; and, although we may not agree with Dr.
Wilson, that "the modern prison is in all sanitary essentials the best
existing type of what a healthy dwelling ought to be," it is
nevertheless certain that the health of the inmates is much more
carefully consulted in planning a penitentiary than it usually is in
planning a college, a hotel, or a dwelling-house. Matters are
gradually improving in this respect: the worst of the tenement-house
rookeries and fever-nests in most of our large cities have been
improved or abolished, and our wealthier citizens are beginning to pay
some attention to their house-drainage as well as to the pattern of
their mantelpieces. But the great majority of men are still careless
and negligent as to the sanitary condition of their homes, and
probably two physicians out of three live in houses in which numerous
defects would be pointed out by a sanitary engineer--defects of which
they are themselves more or less aware. The majority of people in our
large cities under existing conditions cannot afford to have healthy
houses, and the great causes of the excessive mortality, and brevity
of life, in all such cities, are poverty and overcrowding, the latter
resulting from the former. The problem as to the best mode of
improving the sanitary condition of the tenement-house population does
not, however, come before the practising physician for special
consideration, and need not be considered here. Nor is the physician
liable to be consulted with regard to the sufficiency, from a sanitary
point of view, of the plan of a house yet to be built, although he
will occasionally be asked as to the healthfulness of a proposed site.
The questions which he will be asked are such as the following: "Is
the cause of this particular case of disease in the house, or
connected with it? and if so, what is it?"--"Do you think this is a
healthy house?"--"Is the location a healthy one?"--"Is it necessary
that I should give up this house to preserve the lives and health of
my children?" While it is, of course, often impossible to answer with
precision such questions as these, an answer of some kind must be
given; and this should not be a mere random guess, but based on a
deliberate estimate of the probabilities in the case. The
healthfulness of a house is to be judged of, in part, from its
history, if it be possible to obtain any; in part, from such facts as
can be discovered by a careful examination of the premises and
vicinity. The sanitary history of a house is the history of the
diseases and deaths which have occurred in it, together with a set of
plans showing the precise location and character of the house-drainage
and of its fresh-air supply. Such a record is in most cases,
unfortunately, not attainable, although to a person proposing to buy
or rent a house it would often be quite as important as a record of
title. In a well-organized health-office it should be possible to
ascertain the number and causes of the deaths which have {187}
occurred in any given house or square in the city, and also the
character and location of its drainage and sewer connections. Such
records are especially valuable in an investigation of an outbreak of
disease in a community.

The sanitary inspection of a house includes the site and the building
itself. The character of the site is mainly determined by its dryness,
by the presence or absence of organic matter in the soil, and by its
porosity taken in connection with the character of the vicinity.
One-third of the volume of some soils consists of air, and all dry
soils and rocks contain a much larger quantity of air than is commonly
supposed. The influence of soil upon health is exerted mainly through
the media of water and air, but it also affects temperature and
vegetation, being an important factor in climate. Residence on a damp
soil has a tendency to produce diseases of the lungs, and especially
phthisis; but how it does this is unknown, though it would be easy to
construct a plausible theory in connection with the supposed causation
of phthisis by a bacillus. The practical point for the physician is,
that the prevalence of phthisis in a locality, even if it be so
limited as to comprise but a single house, should cause suspicion and
investigation as to the character of the soil-drainage. Soil-moisture
is also an important factor in the development of periodical fevers,
and the effect of thorough drainage in diminishing malaria is now
generally understood.

It sometimes becomes an important question as to the influence which a
collection of water, such as a mill-pond or a reservoir, has upon the
health of a community, and the physician may be called on for an
opinion in such cases where large property interests are involved. The
essential points to be borne in mind are--first, that stagnant water
and damp soil do not in themselves produce malaria; there is something
else necessary, which is commonly designated by the word "germ."
Second, that they are in most cases essential conditions for the
production of the disease, so that if removed the disease will
disappear. Third, that the development of malaria may follow either
the rise or fall of the ground water. Fourth, that the condition of
the border of the collection of water as to presence of organic matter
and moisture is of more importance than the pool itself. And, finally,
that each case is a problem by itself, to be determined by the history
of the sickness of the vicinity, and that only probabilities can be
stated in any case, although these probabilities may be so great as to
amount, practically, to certainty. Of the four factors which appear to
be essential to the production of the malarial poison--viz. moisture,
high temperature, organic matter of vegetable origin, and certain
micro-organisms--the first is the one which in any given locality is
most under human control; it is the link in the chain of causation
which is most easily broken.

The influence of the rise and fall of the soil water in typhoid fever,
upon which so much stress is laid by Pettenkofer and others, no doubt
exists, acting in some cases through pollution of the drinking water
by the subsoil water leaking through a polluted soil; in other cases,
perhaps, by air from the soil bearing the unknown germ. The filtering
power of soil as regards air is, however, very great, a few inches of
sand being sufficient to remove the ordinary germs of putrefaction
from air drawn through it, and this for a long period; while, on the
{188} contrary, many feet of the same sand will not remove the germs
from water passed through it. Usually, as Dr. Parkes remarks, in an
examination of soil the immediate local conditions are of more
importance than the general geological formation, yet this last, as
influencing conformation and the movement of water and air over and
through a country, is also important. The practical questions on this
point are, what higher ground than the site in question exists in the
vicinity? what are the character and direction of the strata between
such elevation and the site? and, what sources of soil-pollution exist
on the higher level? As to the site itself, is it on made ground? what
is the height of the foundation above the subsoil water? and, what
precautions have been taken to secure drainage and to cut off
communication between the interior of the house and the ground air?
Probably a trial excavation or boring may be necessary to determine
some of these points.

The level of the subsoil water should be at least five feet below the
foundations, although it is often impossible to obtain this. At all
times when the temperature of the house is higher than that of the
external air--_i.e._ during a large part of the year and nearly every
night--there is a strong and constant aspirating force at work to draw
into the house, through the cellar floor and walls, all gases and
vapors contained in the adjoining soil. If this soil contains a large
proportion of organic matter, as is often the case in filled-in ground
in cities, or if there be a leaky cesspool or sewer or gas-pipe under
or near the house, the ground air passing into the house may be of
such a character as to be positively dangerous to its occupants. For
this reason it is very undesirable to have a sewer or soil-pipe
crossing beneath the site of a house, and when such location is a
necessity, as it often is in cities, the soil-pipe should be laid in a
cement-lined trench covered with a movable flap, so that it can always
be easily inspected and any leaks detected and remedied. Dampness in
the cellar or basement of a house is always a sign of danger. The
exhalation of gases and vapors from the ground into the house can be
to a great extent cut off by a layer of impervious material, such as
concrete covered with asphalt, but this layer must cover the sides of
the cellar as well as the floor to be thoroughly efficient. If a house
have no cellar, the space between the floor and the ground should be
thoroughly ventilated; and for this purpose, as well as to secure
cleanliness, the floor should be sufficiently elevated to permit of
easy access beneath it.

Next to its dryness, the nature and condition of the arrangements for
removing excreta and soiled water from a house are of the greatest
importance in determining its healthfulness; and in cities it is with
regard to the sufficiency of these, including the whole system of
house-plumbing and pipe-fitting, that the inquiries of one wishing to
determine as to the presence or absence of causes of disease will most
frequently be directed. The soil-pipes, etc. of a house are commonly
referred to as constituting the system of house-drainage, but it is
desirable to use another term, for we need the word "drainage" to
describe the removal of surface and subsoil water, and it should be
distinguished from "sewerage," which has a different purpose and
requirements.

In a properly-arranged system of house sewerage all the pipes, traps,
etc. are easily accessible for purposes of inspection, and an
examination of them is a comparatively simple matter. This examination
is to be {189} made with reference to the following points: 1. Are all
the pipes, joints, and connections air-tight? 2. Is the soil-pipe well
ventilated, or has it dead ends? 3. Is the communication between the
soil-pipe and the street sewer uninterrupted? 4. Are the pipes
properly trapped, and is there liability to the removal of water from
any of the traps, either by siphonage or evaporation, to such an
extent as to break the seal? 5. Is the water-supply of each closet
entirely cut off from the main supply to the house by means of a tank
or cistern?

In houses as heretofore constructed it is often very difficult to
obtain satisfactory information upon these points, because a large
part of the soil-pipe and its connections is buried beneath the house
or concealed in the walls or floors; in which case the services of a
skilled mechanic will usually be necessary to obtain access to the
various parts of the system. In a paper of this kind it is of course
impossible to go into details as to methods of inspection, or as to
what is and what is not satisfactory; but the following are the
general principles upon which a judgment as to the merits of a system
should be formed, and these should be so clearly understood by every
physician that he can be neither persuaded nor frightened into
thinking them incorrect by the eloquence of the man with a patent
remedy to dispose of. The principal dangers to health from house
sewerage are due, first, to the passage of air from the general system
of sewers or from a cesspool into the house through the soil-pipe and
its connections; second, to the generation of offensive and dangerous
gases and organisms in the soil-pipe itself, and the passage of these
into the house; third, to leakage of soil-pipe causing contamination
of the water-supply either by improper connections of water-pipes with
water-closets or slop-hoppers, or by contamination of wells, cisterns,
or tanks with sewage or sewer gases.

There is, of course, no such thing as a sewer gas having a definite
and distinctive composition, and the nature of the mixture of gases in
sewers is constantly varying according to season, temperature, etc.
The tendency which sewer air has to cause disease depends in part upon
certain gases, in part on minute particles of solid or semi-solid
matter which are suspended in the air. In rare instances the sewers
also contain illuminating gas, derived from leakage of gas-pipes in
the vicinity. These gases produce debility, headache, loss of
appetite, etc. As found in sewers and soil-pipes, they are so diluted
that they are not absorbed by the water of a trap and given off on the
other side to a sufficient extent to produce an evil effect. The air
in a soil-pipe which is not ventilated is much more impure than that
of the ordinary sewer, since the process of decomposition is
constantly going on in the slimy coat which lines the interior of the
pipes; and it is for this reason that it is so important to secure
thorough ventilation of all the soil-pipes in a building. When this
ventilation is secured, the proportion of dangerous gas in the pipes
becomes very small, and the amount absorbed by the water in traps is
almost inappreciable. The chief danger to life from sewer and
soil-pipe air arises from the presence of minute particles of organic
matter, dead and living, the so-called germs. Danger to life from
these germs cannot be entirely removed by dilution, as can be done
with gases. It has been found by the experiments of Dr. Carmichael and
Dr. Wernick that an ordinary water-trap entirely prevents the passage
of these germs, and that organic putrescible fluid will remain
unchanged when exposed only to the air immediately {190} above such a
trap. A pin-hole or minute sand-crack in the soil-pipe, or a very
slight defect in a joint, is far more dangerous than a trap.

The forms of disease produced by sewer air and its contents are more
especially diphtheria, typhoid fever, and ill-defined disorders of the
throat and digestive organs. It is possible that the germs of other
specific diseases, such as scarlet fever, may be at times transmitted
through sewer air, but such transmission must be very rare. While it
is true that the germs of the specific diseases are very rarely
present in sewer air, the house system of sewerage must be arranged as
if they were always present, in order to obtain security. It must also
be remembered that a system originally well planned and properly
constructed will not always remain so; the pipes will corrode, the
joints will become loosened, the valves will become clogged, and
whenever alterations or repairs are made there is always danger of
injury. Bearing these points in mind, the method of investigating a
system can be readily understood.

The first step is to ascertain whether there is a trap outside the
house disconnecting the sewer from the house system and permitting
inspection. If there is not, the first thing to be done is to make an
excavation and open the drain at the proper point for placing such a
trap. The next step is to set the water flowing in the various closets
and watch the flow at the external trap, or opening, which has been
made to ascertain whether there is any obstruction in the pipe within
the house. If the sewer is properly arranged for inspection, as has
been above suggested, to determine whether there is any leakage from
the sewer under the house will be an easy matter; if, however, it is
buried beneath the cellar floor, as is usually the case, an excavation
should be made along the floor in the line of the pipe, with a view to
having it properly arranged, as well as for the purpose of examining
the soil. It may also be tested by opening the upright soil-pipes at
the farther end of the house-drain at the height of three or four feet
above the floor and pouring water into it, having temporarily stopped
up the drain at the external trap or opening. If the water remain at a
constant level in the upright piece, the sewer is water-tight; if not,
the leakage may be ascertained by the rate at which it sinks. Having
settled this, the next point is to determine whether all the
soil-pipes are air-tight and properly trapped. The test usually
applied for this purpose is the pouring of a small quantity of strong
oil of peppermint, followed by a dash of hot water, into the top of
the soil-pipe, which should always pass through the roof and be freely
opened to the outer air. If the odor of the oil is perceptible in the
house, it indicates a leak, which must be further sought for. Ether
may be used for the same purpose. The smoke test is, however, the
best, but it requires a special apparatus which as yet is little used
in this country. It is applied by a small machine with a fan, by which
the smoke from burning cotton-waste saturated with oil, or of coarse
brown paper impregnated with sulphur, can be blown into the pipes;
this locates leaks with great precision.

It is not, of course, expected that a physician will personally make
the examination necessary to determine whether the plumbing of a house
is in good order, but he should be able to make it, if necessary, if
for no other purpose than to know whether the inspector employed for
the purpose understands his business.

The dangers to health from a properly-constructed system of house
{191} sewerage, such as is now generally agreed upon by sanitary
engineers, are so very small as to practically amount to nothing,
being, in fact, less than those of a well-kept yard privy of a country
house, setting aside altogether the question of water pollution. The
real difficulties in the way are the expense of such a system, which
is considerable, and the finding of skilled and honest workmen to
construct it and keep it in repair. Not every one who chooses to style
himself a sanitary engineer or a sanitary plumber is to be regarded as
such, by any means, but the physician should make it his business to
know who are really reliable in this respect, for he will constantly
be called in for advice on this point by those who have learned that
good plumbing is the only true economy, but who do not feel themselves
competent to distinguish between good and bad work. The main points of
a satisfactory system are the following.[3]

[Footnote 3: For further details consult the following: _American
Sanitary Engineering_, by E. S. Philbrick, N.Y., 1881; _House-Drainage
and Water-Service_, by James C. Bayles, N.Y., 1878; "House-Drainage
and Sanitary Plumbing," by W. P. Gerhard, in _Fourth Annual Report
State Board of Health Rhode Island_, 1882; _The Sanitary Engineer_, a
weekly journal published at 140 William St., New York City.]

1. All soil- and waste-pipes should be extended up to and through the
roof, and be freely open at the top. The extension of the soil-pipe
should be full size--_i.e._ from four to six inches in diameter.

2. There should be a fresh-air inlet in the house sewer just outside
the house, and between this inlet and the main sewer should be a trap
so arranged as to permit of inspection. This prevents the ventilation
of sewers through the soil-pipes. If a perfect system of sewers,
uniformity of house-connections, and uniform height of houses could be
guaranteed, this inlet and trap would not be so necessary, although
even then it would be useful.

3. Every water-closet, wash-bowl, bath-tub, sink, etc. should have a
trap placed as close to it as possible. This trap is desirable,
whether the discharge be into the sewer system or not. For example, a
kitchen sink, the pipe from which passes to the outer air and
discharges there, should be trapped, for this pipe is foul, and if it
be untrapped will act as an air-inlet.

4. The nearer to the soil-pipe that the fixtures can be arranged the
better. It is especially desirable to avoid the necessity for long
horizontal waste-pipes from stationary waste-bowls and from bath-tubs.

5. Bell traps, D traps, bottle traps, and mechanical traps are
objectionable. The S trap is, upon the whole, the best, but it should
be provided with a vent-pipe to prevent siphonage.

6. The best kind of water-closet for general use is probably some form
of what are known as the wash-out closets. They are made in one piece
of earthenware, have no machinery inside them, have a quantity of
water in the basin into which the excreta drop, and do not require a
separate trap beneath them. Each closet must, however, be carefully
tested by itself: a very small warp or twist produced in the baking
may so interfere with the siphonage as to make it practically
worthless, and the basin cannot be altered or repaired. For use in
public places some of the hopper closets are very satisfactory, the
best which I have examined being the Rhoads Hopper and the Hellyer
Hoppers. Where there are no {192} children, and it is certain that the
fixtures will be used with reasonable care, valve closets may be used.
No form of pan closet can be considered as satisfactory, nor have I
found any form of plunger closet that I would specially recommend.

7. Water-closets should always be flushed from a special tank provided
for the purpose, and never direct from the main system of water-pipes.
The flush must be large and rapid, and this requires a large
supply-pipe, and for many forms of closets a flushing rim. Whatever be
the form of closet, it should not be encased in a wooden box or
closet, as is usually done, but it should stand freely exposed to
light and air. Sanitarians commonly advise that water-closets should
be located in outer walls and have an open window for ventilation.
Such a position is usually impossible, and is not specially desirable
in our climate. The open window acts as an inlet quite as often as it
does as an outlet, and the air of the closet is thus swept into the
house. The room should be ventilated in such a way that the tendency
of the air at the door shall always be from the house into it. This is
to be effected by a shaft passing through the room up and through the
roof; and it is well to have this shaft take its air-supply from just
behind the closet or from beneath the seat. It is best made of
galvanized iron, and at a convenient point should be expanded into a
lantern and have a gas-jet placed in it. The air-supply for the closet
is to be taken at the bottom of the door or through a transom or
louvres. Ventilating pipes from a water-closet should never be run
into a brick flue. While it is not so important as many writers seem
to think that a water-closet should be placed on an outer wall, it is
very important that it should be as light as possible, and the placing
it in a dark corner in the basement or under the stairs is very
objectionable.

8. No overflow-pipe from any cistern or tank, except the one used for
flushing water-closets, should be connected with the soil-pipe or
sewer. Trapping such an overflow-pipe does not prevent the danger. The
same rule applies to waste-pipes from refrigerators and to the
waste-pipes from the safes which are commonly placed beneath fixtures.

9. Grease-traps placed inside a house--for instance, beneath the
kitchen sink--are of very doubtful expediency, and if they cannot be
placed outside, they had better not be used at all.

In an unsewered city one of the first things to be considered in a
sanitary inspection is the manner in which the sewage of the premises
is disposed of. The question is, however, by no means superfluous in
many sewered cities, for cesspools and vaults are to be found in most
of them, and not only in yards, but beneath houses, and houses of the
better class. A privy-vault or cesspool beneath a dwelling or near its
cellar walls is always to be considered as very dangerous, for it is
practically impossible to prevent the passage of gases from it into
the interior of the house. A cesspit is a dangerous thing anywhere,
even in the country; but in a city it is so dangerous that its
existence should not be permitted.

If the water-supply of a house is derived from a well, and there is
reason to suspect that this may have been contaminated from a
neighboring privy-vault, the first test to be applied to the water is
that for the detection of chlorides. If none are present, the water is
not polluted. If they are present, the quantity is to be noted, and a
peck or two of common salt is then to be thrown into the suspected
vault. If repeated {193} examinations of the water show a marked
increase in the amount of chlorides present, it may be inferred that
the contents of the privy pass to the well. The fact that the water of
infected wells and springs is usually much liked and sought for is to
a considerable extent due to the presence of these chlorides. Wanklyn
recommends the addition of 50 grains of common salt per gallon to
drinking water to render it palatable. Popularity of a certain well is
therefore a reason for suspecting its purity.

This subject may be dismissed with one caution. Taking the
dwelling-houses of a city or town as they come, it will be found on
examination that over half of them would be described by a competent
inspector as being in a condition which might produce disease. It is
therefore more than an even chance that in any case of disease some
sanitary defect will be found about the premises quite irrespective of
any direct causal connection with the case. Let the physician
therefore be cautious in deciding as to such causal connection, and
not conclude that because a case of diphtheria or typhoid fever and a
leaky soil-pipe occur in the same house, therefore one is the cause of
the other. Such cases occur in houses whose sewerage is perfect and in
houses which have no sewerage, and it is folly to attribute them
exclusively or mainly to sewer gases.

The same caution applies to investigations into the causes of a sudden
outbreak of disease in a community where a number of cases occur
almost simultaneously or in rapid succession. Such an outbreak may be
due to direct contagion, although sometimes very difficult to trace;
as, for example, an explosion of small-pox in a community largely
unprotected by vaccination, and where, owing to circumstances
connected with the first few cases, a large number of persons have
been exposed to the cause about the same time. The same applies to an
apparently sudden development of yellow fever throughout a city.

Another cause of such outbreaks is a polluted water-supply, as in some
epidemics of diarrhoeal disease or of typhoid fever. If the outbreaks
of these diseases are pretty sharply localized, and depend upon the
fouling of a well or wells, it will usually not be very difficult to
trace this cause. If, however, the town has water-supply by means of
pipes from a single source, while the outbreak of disease is limited
to a part of the town or to a single large building, it will probably
be almost impossible to establish any connection between the disease
and the drinking water. The possibility of the contamination of a part
only of a system of general water-supply by means of the drawing of
foul air into the temporarily empty pipes connected directly with a
water-closet flush should never be forgotten, for such a case has
actually occurred, and the account of its discovery is one of the best
pieces of sanitary detective work with which I am acquainted. If the
outbreak of typhoid fever cannot be traced directly to the
water-supply, the next point to be investigated is the milk, and after
that other possible modes of the conveyance of the contagium.

In cases of obscure disease characterized by fever of no definite
type, disorder of the digestive organs, headache, malaise, etc., and
which seem to be connected with residence in a particular house or in
one room in a house, the possibilities of arsenical poisoning from
wall-paper or hangings should be remembered, for much useless
medication and some real danger will be avoided if this cause be
promptly recognized. The effects {194} produced by arsenical dust are
very various, and simulate sometimes some of the specific fevers,
indigestions, or neuroses in a way that is very puzzling if the true
nature of the case is not suspected. The popular notion is that
arsenic is found only in greens (more especially in bright greens in
wall-papers), whereas in fact it is found not only in dull greens, but
in some browns, grays, and dull reds. The test for its presence in
quantity sufficient to be a cause of disease is an easy one, and is
fully given in any manual of chemistry or toxicology.

VI. OCCUPATION.--While the effects of occupation upon health are no
doubt great, they are in many cases so blended with those of condition
in life, including habitation, food, and intemperance, that it is very
difficult to distinguish them. In attempting to investigate these
effects by means of statistics, it is necessary to beware of a fallacy
which not unfrequently vitiates the conclusions drawn from otherwise
carefully prepared tables intended to show for different occupations
either the relative mortality or the average age at death. This
fallacy lies in the fact that the number of persons engaged in each
business is unknown; that, in this country at least, men often change
their occupations; and that certain trades or professions are chiefly
carried on by persons of certain ages. This last is perhaps best
illustrated by the remark of Dr. Farr, that the fact that the average
age at death of second lieutenants is much less than that of
major-generals proves nothing with regard to the comparative
healthfulness of the two grades. Statistics showing merely the number
of a particular class or grade dying in a given time are absolutely
worthless, unless the number of the same class or trade living at the
same time is also given.

It is also necessary to bear in mind the power of habit and the
effects of natural selection, especially when the effects of an
unhealthy occupation are immediate and marked upon those unfitted for
them. For example, young men, when first employed as scavengers or in
sewage-pumping works, usually suffer from disorders of the digestive
organs. A certain number find it necessary for their health and
comfort to soon leave the business; some acquire protection by passing
through an attack of fever; and by this process of selection a class
of men are obtained who seem to thrive in the midst of filth and
remain unaffected by effluvia which will promptly cause illness in
those unaccustomed to them. When men find that, to use a common
phrase, they "cannot stand" a particular kind of work, they are apt to
give it up and try something else, especially if the effects are
prompt and well marked.

Much attention has been given of late years in England, France, and
Germany to the means of protecting both the workmen and the
neighborhood from the ill effects of dangerous and offensive trades,
and the reports of the medical officer of the Privy Council and of the
Local Government Board are a mine of information on this subject. It
may be truthfully asserted that in those trades in which the special
danger is caused by dust of various kinds, or by gases, or by metallic
poisons--and these three include the greater number of the dangerous
occupations--it is almost always possible to so arrange the work as to
make it comparatively healthful and harmless. Overcrowded and
unventilated workrooms are responsible for much disease, and when to
these is added the risk of metallic poisoning, as is the case with
printers, artificial-flower {195} makers, etc., bad results are almost
sure to follow. It is curious that so comparatively little ill effect
seems to be produced by exposure to great heat, as in stokers,
foundry-men, glass-blowers, etc.; but further information is needed on
this point as to the real facts in the case. In some occupations the
chief evils arise from want of out-door exercise, a subject which will
be considered presently. The want of useful or interesting occupation
sometimes becomes indirectly the cause of disease among the wealthier
classes, and the giving a man or woman something to do is in such
cases the best prescription which can be made. This danger is
especially apt to occur in the case of an active, energetic man who
retires from business, intending to spend the rest of his life in
pleasure and in the enjoyment of the fruits of his industry: the
preventive or remedy is obvious.

VII. FOOD.--The comfort, energy, usefulness, and moral character of a
man depend largely upon his digestion, and this in turn depends
largely on what it has to act upon--viz. food. There are, it is true,
many men who boast that they can digest anything, and who are really
comparatively indifferent as to the kind, or mode of preparation, of
the food set before them, so that the quantity be sufficient; but were
it not that habit and heredity--which is the family habit--combine
with natural selection to adapt men to their food, it is probable that
the frying-pan, the pie, and soda-bread would depopulate large
portions of this country. As it is, there can be no doubt that fried
food swimming in grease, leathery, sodden pie-crust, and heavy bread
tend to make life short and the reverse of merry; and when the effect
of these is combined, as it often is, with those of malaria, damp
soil, and a free use of whiskey, the result is plenty of work for the
doctor and very little to pay him with. This state of things is being
gradually improved, but in all classes of society and in almost all
parts of the country the rule is, that while the raw materials of food
are abundant and of excellent quality, the cooking is bad. This is
due, in part, to an idea that it is to a certain extent discreditable
to a person that he should give much attention to his food, at least
so far as its appearance and taste are concerned, and that a man who
can plan a good dinner must be more or less of a sensualist and a
glutton.

Another popular error is, that a large amount of disease is due to
overeating, and that abstemiousness in diet is either certain to
secure health, or is, at all events, indispensable for this purpose.
Upon this point the reader should consult a capital paper by Dr.
Austin Flint on "Food in its relations to personal and public health,"
which will be found in vol. iii. _Reports American Public Health
Association_, N.Y., 1877. After remarking that many of the popular
errors about food and diet are relics of old and abandoned medical
theories, one of which is embodied in the not uncommon advice that one
should always stop eating before the appetite is fully satisfied, and
that food should only be taken at regular fixed periods, no matter how
hungry one may be, he says: "Physiology, experience, and common sense
are alike opposed to these popular notions relating to food.
Conditions for perfect health are, first, a sufficient appetite;
second, the gratification of normal appetite before the want of food
reaches the abnormal degree expressed by hunger; third, the
satisfaction of appetite by an adequate quantity of food. These
conditions of health are fulfilled by compliance with instructive
provisions for {196} alimentation. But, it will be asked, is appetite
infallible as a guide in dietetics? Following it as a guide, is food
never taken beyond the requirements of health? I answer, It is a
reliable guide under normal circumstances. The inevitable
circumstances of life are often not altogether normal, although
producing no distinct morbid affection. Experience teaches, for
example, that in a state of fatigue or exhaustion (which is not a
normal state) inconvenience may arise from the full gratification of
appetite; that if unusual exertions, mental or physical, are to
follow, a hearty meal may occasion disturbance; and other examples
might be added. Irrespective of abnormal or disturbing influences, if
appetite be not infallible, it is, at all events, more reliable than a
rule based on theoretical ideas, popular notions, or on purely
physiological data. Moreover, it was evidently not intended that the
quantity of food should be accurately adjusted to the needs of the
economy. To do this is impossible, and therefore it is necessary to
elect between the risk of taking either more or less food than is
actually required. Which is to be preferred? Undoubtedly, it is vastly
better to incur the risk of taking too much than that of taking too
little. Nature provides for a redundancy, but there is no provision
against a persistent deficiency. Ex nihilo nihil fit. An ample supply
of alimentary principles is indispensable to nutrition; and inasmuch
as the supply cannot be made to contain precisely the needed amount of
the different alimentary principles, we may say that a superabundance
of food is a requirement for health.

"As in appetite we have a guide in respect of the times of taking food
and the quantity to be taken, so taste is a guide in respect of the
kinds of food required. The discrimination of food with reference to
the wants of the system is the evident purpose of the sense of taste,
and the enjoyment connected with this sense was designed to afford a
security, in addition to appetite, for adequate alimentation.

"Among professional men and those who live sedentary lives the mistake
is not uncommon of paying too much attention to the sensations after a
meal, and deciding therefrom whether certain articles of food are
unhealthy or not. If the man who does this is not already dyspeptic,
he will pretty surely become so. The remedies in this case are
exercise and attracting the attention to something else."

A physician ought to understand something of cooking, and a short
course of practical instruction in what might be dignified as the
culinary laboratory would be of more real value to him than some of
the branches which are now considered indispensable in the medical
curriculum. He should know why oysters are the best thing with which
to begin a dinner, and why a cocktail is one of the worst; how to make
a salad, or a cup of good coffee, or a perfect consomme; and a number
of other things pertaining to gastronomy of which most people are
woefully ignorant.

It is not within the scope of this paper to give details with regard
to the diet of either the sick or the well, but it seems proper to
remark with regard to the feeding of infants, more especially in our
large cities in the summer months, that all the various patent
preparations for infants' food are more or less pernicious, and should
be discountenanced by all medical men. The proper food of an infant is
milk--human milk if it can be had, cow's milk if it cannot. If it be
remembered that an infant suffers {197} from thirst as well as hunger,
and care be taken to give it enough pure cool water to quench this
thirst, it will be found that in most cases it will thrive on pure
cow's milk.

With regard to adulterations of food, the only form of such
adulteration found in this country, which has any special interest
from the sanitary point of view, pertains to milk. This adulteration
is in most cases the dilution of the milk by water, and this is very
common in large cities. The danger from the use of such milk is by no
means confined to infants, and it is probable that a larger proportion
of the typhoid fever, diphtheria, scarlet fever, cholera infantum, and
diarrhoeal diseases in our cities is due either directly or indirectly
to the milk-supply than is now even suspected. The possibility of this
mode of origin should always be borne in mind in investigating the
causation of such affections.

A very large amount of food is now furnished preserved in tin cans,
and it is almost invariably of excellent quality. There is a
possibility of the contamination of such food by the salts of lead or
tin, but such contamination to an extent which is injurious to health
must be so extremely rare as to be hardly worth considering. The
danger from the entrance of parasites, such as trichinae, etc., in the
food is also extremely small--in fact, is nothing where the food is
properly cooked.

Milk has so often been the cause of disease, and is so universally
used, that it seems worth while to refer to it again. The special
aptitude of milk for absorption of odors has long been known, and of
late years it has been clearly proven in a number of instances that
milk has been the means of conveying the cause of typhoid fever and of
scarlatina. Diphtheria, yellow fever, and intermittent fever have also
been supposed to be conveyed by milk. The variety of nutritive
principles contained in milk, which makes it so valuable as a food,
also gives it the power of sustaining many different sorts of minute
organisms, and it perhaps comes as near being a universal
culture-fluid as anything yet devised for that purpose. The
possibilities of the contamination of milk are so numerous, and
especially in the case of that furnished from small establishments,
that, in the case of outbreaks of typhoid or diarrhoeal diseases in a
town, investigations into causation should always include the milk- as
well as the water-supply. Milk from diseased animals is no doubt often
used without producing bad results, but its effects in conveying to
man the disease known as milk-sickness are well established, and it
has also been known to produce symptoms of the contagious aphthae, or
foot-and-mouth disease, in man, when derived from an animal affected
with that disease. The only danger in the use of the milk of animals
fed upon sewage-grown grass appears to be in the possible
contamination of the milk, after it is drawn, by particles of dust in
the stable, derived from the food or litter of the animal or from
uncleanliness of the exterior of the udder, etc.

VIII. INTEMPERANCE.--Every one knows that alcoholic drinks are the
cause of a vast amount of disease, crime, and misery in all civilized
countries. No one knows how this is to be prevented, for no one knows
how to make the great mass of the people wise and contented. The
effects produced by excessive use of alcohol are well known to all
physicians, and the remedy is self-evident. I see no use in adding to
the heap of useless rubbish which exists in the shape of the great
mass of existing {198} popular literature on this subject, and
therefore leave the subject to the reader, who is quite sure to know
all that is really important on this subject.

IX. CLOTHING.--The hygiene of clothing is also a subject which may be
treated summarily in this paper. People wear what they can afford,
made according to the prevailing style. Diseases due to insufficient,
excessive, or badly-fitting clothing occur most frequently in women
and children, and the use of such clothing is for the most part due to
poverty or fashion, either of which is beyond the power of the
physician to successfully cope with. Here and there, in individual and
exceptional cases, he may be able to do a little good by advising
against tight lacing, high-heeled shoes, insufficient covering for the
chest or legs, etc., and he will find that a knowledge of the
peculiarities of the various styles of modern under-clothing will
sometimes be very useful. Men are, as a rule, comfortably and sensibly
dressed to suit their business and surroundings, and require no advice
on this subject.

X. EXERCISE.--The ease and completeness with which the functions of an
organ or of an organism are performed depend to a great extent upon
the frequency and regularity with which such functions are exercised.
Hence comes the importance of bodily exercise for the preservation of
health, and every physician meets cases of disease due largely to want
of work.

The term "exercise," or "bodily exercise," is commonly used as if it
referred only to the muscles, and the amount of exercise which a man
should take in a day is stated as equal to a certain number of
foot-pounds. The mere giving work to muscles is not, however, exercise
in the sanitary sense. A better definition is that of Du Bois
Reymond--viz. that "exercise is the frequent repetition of a more or
less complicated action of the body with the co-operation of the mind,
or of an action of the mind alone, for the purpose of being able to
perform such actions better." From this point of view it will be seen
that exercise relates quite as much to the nervous system as to the
muscles. When, for example, a student takes a walk over ground with
which he is familiar, and is at the same time so deeply engaged in
thought as to be practically unconscious of what he is doing, only
being recalled to himself, it may be, by arriving at his own door, the
exercise which he has had is but partial and insufficient. Going to
the extreme, we can, as Du Bois Reymond remarks, conceive of a man
with muscles individually exercised until they were like those of the
Farnese Hercules, and yet who would be unable to walk, much less
execute more complicated movements; for the proper co-operation of the
muscles, which is effected through the nervous system, is quite as
necessary as the force of their contraction.

The amount of exercise which is necessary for health varies with the
individual and with age, season, etc., so that it is difficult to
state any general rule upon this subject; but if stated in terms of
muscular force only, the estimate of Dr. Parkes seems a fair
approximation--viz. that every healthy man ought to take daily an
amount of exercise equivalent to 150 tons lifted 1 foot, or a walk of
about nine miles. The majority of trades and bodily occupations demand
at least this amount of work, but in some of them the greater part of
the exertion is made only by certain groups of muscles, and they are
carried on in crowded and {199} ill-ventilated shops. Such workmen, as
well as all who are engaged in sedentary pursuits, require exercise in
the open air--exercise which will bring into play the unused muscles
and will break the train of thought of the professional man.

One of the most important questions with regard to physical exercise
is the extent to, and manner in, which it should be provided for in a
proper system of education. One of the latest and most instructive
articles on this subject is that by Du Bois Reymond in the "Physiology
of Exercise," a translation of which is given in the _Popular Science
Monthly_ for July and August, 1882. He divides the physical training
which is more and more becoming a part of modern systematic education
into three classes: The first, the turning, or gymnastics of the
Germans; the second, the Swedish system, in which the exercises are
limited to very simple though varied movements; and the English
system, or rather want of system, consisting largely of athletic games
and contests of various kinds. His objection to the Swedish system is
that, while it strengthens the muscles, it does not increase the power
over composite movements; in other words, it does not exercise the
nervous system. Naturally, he prefers the German system to any other,
although admitting that the English meets better the demands arising
from our structure. "Were the end masterhood in running, jumping,
climbing, in dancing, fencing, riding, in swimming, rowing, or
skating, then nothing could be more advisable than to practise equally
the necessary concatenations in the actions of the ganglion cells,
without pausing at the not practically applicable preliminary and
intermediate steps of the German turning."

From a sanitary point of view, the gymnasium, as usually located and
managed, is by no means equivalent to out-of-door sports and contests,
although it is often the best substitute for them. The form of
exercise most used by men whose occupation does not involve bodily
labor is walking, and next to this riding. Whatever mode be selected,
it is very desirable that it should be taken for some other object
than that of the mere making muscular exertion, or otherwise it will
soon come to be looked upon as an unpleasant task, the time spent upon
which is given grudgingly; and it will be partially or wholly
abandoned as soon as the immediate discomfort which induced its use
has ceased.

It is not an uncommon error among men engaged in mental work to
suppose that they can, and ought to, take the same amount of exercise
which gives good results in those whose occupations involve physical
rather than mental effort, or to think that the more exercise they
take the more study or writing they are equal to. This is a grave
mistake. Expenditure of brain-tissue is not to be repaired by muscular
exertion, but by sleep and food, and exercise in the fresh air
sufficient to produce appetite and sufficient weariness to ensure
restful sleep is all that is necessary. For a time it is true that the
student or writer who has a well-developed body can continue to burn
the candle at both ends, and win literary honors while also standing
high as an athlete; but this surely leads to physiological bankruptcy
in the end.

It is to be remembered that good muscular development is not
necessarily synonymous with health, and that strength is not a
guarantee against disease. And, while it is true that in this, as in
most other matters of individual hygiene, each man must to a great
extent be a law to {200} himself, and learn by experience what kind of
exercise and how much of it he requires, yet the physician can often
supply the motive which was wanting, or check undue effort. Exercise
for the sake of health and comfort is not an end, but a means; yet if
this means can be made to secure to the patient an end agreeable and
pleasant in itself, so much the better.

XI. CONTAGION AND DISINFECTION.--By "contagion" we mean the
communication of disease from one person to another, either by direct
contact or through some medium, such as air, water, etc. It therefore
includes "infection," which is now generally used as a synonym for it.
The so-called infective diseases of modern German writers
(Infections-Krankheiten) include, besides what are commonly termed in
English, contagious diseases, the so-called miasmatic diseases.

The characteristic of a contagious disease is its specificity; that
is, the disease transmitted is always the same in its essential
characteristics. It does not, however, follow that all cases of the
disease are equally liable or have the same power to transmit it; in
other words, the degree of virulence of the contagiousness is not an
essential characteristic. That the same disease sometimes spreads
rapidly and is very fatal, and at other times seems hardly to have any
contagious properties and is very mild, has long been noticed, and has
been attributed to an unknown something called the medical
constitution of the place--the constitution medicale of French
writers. The true cause is probably very complex, but in some cases,
at all events, it seems to be due to difference in the contagion
itself. If we suppose this contagion to be a minute organism, it is
easy to form a theory as to the cause of these differences, but there
is much careful experimental work to be done before we shall have
positive knowledge on this point. The results obtained by Pasteur in
attenuating the virus of chicken cholera and splenic fever indicate
one line which these experiments will take, and the researches of Koch
point out another.

The diseases which spread by contagion until they form epidemics are
those which have from the earliest times attracted the most general
attention, and which have given rise to organized efforts for
prevention--_i.e._ to public hygiene.

They are also the diseases which have given rise to the most bitter
controversies among medical men as to the means of their propagation
and the best methods of prevention. Plague, cholera, yellow fever, and
typhus are those with regard to which this difference of opinion has
chiefly occurred--one party considering their chief cause to be
contagion, or specific germs derived directly or indirectly from the
bodies of the sick; the second party declaring that they are due to
filth plus an unknown something, which is variously termed epidemic
constitution, pandemic wave, Providence, or _x_. The great majority of
opinions at present is in favor of the view that they are all
contagious, but not all, or always, contagious from person to
person--that they spread from infected localities, which localities
receive their infection from cases of the disease. The best means of
dealing with them under ordinary circumstances are now tolerably well
understood, and where these means can be commanded--as, for instance,
among troops in time of peace--epidemics of these diseases can be
stopped with great precision and promptness by isolation and
disinfection.

{201} By "isolation" is meant not only the separation of the sick from
the well, but the isolation of the infected locality or water-supply
until it has been rendered harmless.

By "disinfection" is meant the destruction of the specific causes of
disease, and more especially of the infectious or spreading diseases.
A disinfectant is not necessarily an antiseptic or a deodorant, nor
are these last necessarily disinfectants. The best practical
antiseptic for sanitary purposes is cleanliness; the best
disinfectants are heat, bichloride of mercury, sulphate of iron,
chloride of zinc, sulphurous acid, chlorine, sunlight, and pure air,
and, for yellow fever, cold. With our present very imperfect knowledge
of the nature of specific causes of disease which we wish to destroy,
we have no means of determining the presence of these causes in or on
an article of clothing or of furniture, or in a room or other
locality, except by the production of their specific effects on man or
by inductive reasoning; in other words, we can only say that it is
more or less probable that such causes are present. This makes it
necessary, or at least expedient, to employ disinfectants in many
cases where the presence of such causes is doubtful. The practical
difficulties are, first, to bring the disinfecting agent into such
relation with the causes of disease that it can act upon them, and act
upon all of them; second, to avoid unnecessary destruction or injury
of things which should be preserved. The majority of the causes of
disease upon which we wish to act by disinfectants are probably minute
particles of solid or semi-solid matter which are living, and may be
conveniently designated by the word "_germs_." In the presence of
moisture the destruction of the vitality of these germs can be
effected with comparative ease and rapidity, but when they have become
dried, or, as in the case of the bacilli, are in the form of spores,
it is a more difficult matter.

To illustrate the methods to be pursued and the precautions to be
taken, let us suppose the physician to be called on for directions as
to the management of a case of scarlatina, the object being to prevent
its spread. The first thing to be done is to get the patient in a room
by himself, and to leave nothing in this room which is not necessary.
Remove the carpet, curtains, and all stuffed or upholstered furniture.
Let the nursing be done, as far as possible, by one person only, and
do not allow others, and especially children, to enter the room, no
matter if they have had the disease. The danger of contagion depends
upon particles coming from the skin and mucous membranes. All excreta,
and more especially the sputa or discharges from the mouth or nose,
are to be treated as dangerous. The excreta should be received in
vessels containing a solution of sulphate of iron, one and a half
pounds to the gallon. All clothing, towels, bed-linen, handkerchiefs,
napkins, etc. should be placed in a solution composed of four ounces
of sulphate of zinc and two ounces of common salt to the gallon of
water as soon as they are not needed for further use. Especial care
should be taken that none of these articles are removed from the room
while dry, and while they are in the room, and before they have been
moistened, they should not be shaken or disturbed more than is
absolutely necessary. If for any reason the zinc solution above
referred to is not at hand--which should very rarely be the case--the
clothing, etc. should be placed in a bucket, tub, or boiler containing
enough scalding water to entirely cover them, and be removed {202}
from the room in this vessel. All such articles should be boiled at
least one hour.

No sweeping or dusting in the ordinary way is to be done in the room;
dust and dirt are to be removed by damp cloths, which are to be
treated like the bedding and clothing. The great object is to prevent
as far as possible the production of dust in the atmosphere of the
room. The entire body of the patient, including head, face, and limbs,
should be kept thoroughly anointed with camphorated oil, vaseline, or
some similar substance, and especial care should be taken in this
respect during the period of convalescence so long as any roughness or
desquamation of the skin continues. No toys or books which it is
desired to preserve should be allowed to remain in the room, and under
no circumstances should books or toys be borrowed to amuse the child
if they are to be returned. The best way to disinfect such articles is
to burn them in the room.

When the patient is fully convalescent and all desquamation has
ceased, cleanse him thoroughly with a warm bath and soap for four
successive days. If at the end of that time no roughness of the skin
remains, he may be dressed in clean clothes and taken from the room,
for he is no longer a source of danger. The room itself and the
furniture are then to be thoroughly cleansed and disinfected. The
ceiling and walls, if of ordinary hard finish, are to be scraped and
whitewashed. All woodwork should be rubbed with damp cloths and the
floor well scrubbed. Care should be taken to remove all dust from the
ledges over windows and doors. All the cloths used in this cleansing
process are to be burned.

If these directions have been carefully carried out, there is no need
for further disinfection. But if upholstered furniture has been
allowed to remain in the room, or other articles which cannot be
burned or scrubbed or soaked in the zinc solution, it may be desirable
to attempt to disinfect the whole room and its contents by means of
chlorine or sulphurous acid gases. Of these, sulphurous acid gas is
the cheapest, and upon the whole the best, but it must be used in
large quantity, and for a longer time than is customary, if it is to
be relied upon. For this purpose all openings into the room should be
closed, and pillows, mattrasses, upholstered furniture, and articles
which cannot be treated with the zinc solution should be opened, so
that they may be exposed throughout to the fumes. The sulphur should
be burned in an iron pan or pot, placed in a tub containing water or
upon a large surface of sand. About 18 ounces of roll sulphur should
be used to each 1000 cubic feet of space, and after twenty-four hours
12 ounces more should be burned and the room be then closed for
twenty-four hours longer, after which it may be opened and aired. In
case of death the body should at once be wrapped in a sheet thoroughly
soaked with the chloride of zinc solution, and either be placed in an
air-tight coffin at once or be buried without delay. The funeral
should be strictly private, and the sheet referred to should not be
disturbed or the body exposed to view.

The cases most liable to spread the disease are those in which the
attack is very light and the child is not confined to its bed. It is
desirable that children in a house in which there are cases of scarlet
fever should not be allowed to attend school or mingle with other
children who have not had the disease.

With regard to disinfectants, it may be well to note that none of the
{203} various patent disinfectants are superior to bichloride of
mercury, chloride of zinc, sulphate of iron, chlorine, and sulphurous
acid; very few are equal to them, and none cost so little. As a
gaseous disinfectant for rooms, etc. chlorine is superior to
sulphurous acid, but it has the disadvantage of injuring metals, is
not so easily applied, and is more costly. It will destroy the
vitality of the spores of the bacilli more rapidly and certainly than
sulphurous acid, which last, to make sure work, must be exhibited for
a much longer period than is customary. I should not feel confident as
to the thorough disinfection by sulphurous acid of the hold of an
infected ship unless the fumes had been applied for sixty hours.
Carbolic acid as ordinarily used is an antiseptic rather than a
disinfectant. Its vapor in a sick room is absolutely useless. When
applied in strong solution it is effective, for a time at least, but
as thus used it is expensive, its odor is unpleasant to many, and
masks the odors from putrefying substances and excreta, etc., thus
preventing the warning which these odors would give. Its use is in
many cases very much like removing the rattle from the rattlesnake.

The suggestions made above for limiting the spread of scarlatina from
a case to be treated in the residence of the patient apply--with
certain modifications for each form of disease, which will readily
suggest themselves to the physician--to all the affections due to
portable contagia.

Among the poorer classes, however, it will often be found impossible
to obtain the separate room and service and the constant intelligent
care which are necessary to ensure the desired result; and in such a
case the patient should be removed to a hospital, for his own sake as
well as for that of the community. The utility of small hospitals for
infectious diseases is by no means generally understood, and very few
of our small cities and towns are provided with anything of the sort.
If the subject is urged on the authorities of a place, the reply will
be that it is an unnecessary expense, that the people would not go to
it, and that such an institution is in itself a source of danger. The
facts are, that such a hospital costs very little, and is the cheapest
insurance against epidemics which a town can have; if it is kept clean
and comfortable, the people will use it freely, and if properly
managed it does not offer the slightest danger to the vicinity. This
question will be further discussed in the last section of this paper.

The principles of isolation as applied to a single case as indicated
above may also be applied to infected localities in case of epidemics.
When taken in time, all diseases which depend upon particulate
contagia for their origin can be stamped out by isolation and
disinfection. Unfortunately, to effect this promptly and successfully
requires money, labor, and the co-operation of the well in the
vicinity; which last it is usually impossible to obtain voluntarily or
to compel sufficiently to secure the desired results. A question which
sometimes arises in case of epidemics, and with regard to the
necessity for which physicians will be consulted, relates to the
closure of the public schools. It is certain that the assemblage of
children in schools exerts a powerful influence on the spread of such
diseases as scarlet fever, diphtheria, and whooping cough. On the
other hand, the closure of the schools infringes upon the rights of a
large number of the community, and if long continued, as it sometimes
must be to be really efficacious, inflicts upon them {204} a permanent
loss. It is, moreover, a confession on the part of the authorities of
inability to induce or compel what must always be a comparatively
small part of the community to take the proper precautions. It is
never justifiable to close schools on account of small-pox, and where
there is a competent health authority supported by the influence of
the medical profession, it must be a very exceptional set of
circumstances which justifies their closure for diphtheria or
scarlatina.

It is not deemed expedient here to discuss the vexed question of
quarantine. It is more important against yellow fever than any other
disease, because every day of delay of the entrance of the disease
which it secures lessens largely the subsequent mortality, since the
duration of the disease is limited by frost. This is not the case with
cholera, and the mere keeping this disease out of a place for a few
weeks does not diminish its ravages when it has once gained an
entrance. To rely altogether on quarantine, either maritime or inland,
to keep yellow fever, cholera, or any other disease out of this
country is a far greater mistake than to neglect it altogether. The
practical way to isolate and quarantine is to get as close to the
affected spot as possible. Precautions at Havana for yellow fever, or
at Hamburg for cholera, are far more useful to the United States than
the same amount of work at our own ports can possibly be; really good
work in this direction must be not only national, but international.

XII. MENTAL CAUSES OF DISEASE.--A man may give too much attention to
his health and the means for its preservation, and the doing so is
both a sign and a cause of disease--probably oftener the former than
the latter, except in cases of psychological epidemics. The power of
expectant attention, especially if accompanied by belief or fear, to
produce derangement of function in the nervous system, and through
this to affect the circulatory and digestive systems, is well known to
medical men. The effects of an undue amount of brain-work, and
especially of the anxiety and worry which often accompany this when it
is specially directed to the acquiring of wealth, fame, or power, are
also familiar to physicians in our large cities. The analogies between
mental and physical exertion are close in some respects, and
especially as to the effects of over-exertion in a limited time under
the influence of excitement.

The danger from simple mental work, such as study, when there is no
excitement from a contest, is small, and depends mainly on lack of
physical exercise and consequent disorder of the digestive organs. The
risk of producing what Fothergill calls "physiological bankruptcy" is
greatest in the youth studying for a prize, the speculator, the man
who feels responsibility which he knows he probably cannot meet. The
danger of injury from overwork under excitement is a very real one in
many of our schools, and, while the evil results are most apparent in
girls of the middle and upper classes, the boys and the young men also
suffer. The system of pass examinations, in which the standing of the
pupil is to be determined, not from the average results of his daily
recitations, but from a single examination at the end of the year,
produces the greatest risks to health; and this is especially the case
where the ambition and pride of the children are stimulated by
competition for prizes, medals, etc. Such systems of grading by a
single final examination should not be used in ordinary schools, and
for some pupils there will always be a risk to health connected with
them even when they are of age. No doubt the stimulus of {205}
competition is useful with the majority of children as well as of
adults, but with some of them it is pretty sure to go too far.

The symptoms produced by undue mental strain are familiar to all
physicians, and there is usually little difficulty in tracing the
effect to the cause when attention has been directed to the matter; in
fact, the patient himself usually knows very well the cause of his
troubles. The remedy is, of course, rest--but that does not mean
idleness. In speaking of occupation, allusion has been made to the
fact that the physician must at times advise his patient as to the
adoption of some pursuit, and in cases of this kind such advice is
also useful.

The effects of mental strain are often mingled with, and aggravated
by, those of stimulants which have been used to spur the flagging
energies. Alcohol, tobacco, opium, or coffee used in this way finally
increase the very discomforts which at first they relieved.


II. Personal Hygiene in its Relations to the Practice of Medicine.

In the preceding section have been indicated briefly some of the
principal causes of disease and the methods for their investigation or
removal. We have now to consider some of the practical applications
which may be made of the laws of etiology and prevention of disease in
the treatment of the sick. While the removal of the cause of illness
by no means always effects a cure, yet the importance of a knowledge
of this cause as an aid to diagnosis, prognosis, and therapeutics is
so evident as to require no proof.

To discuss with anything like completeness the practical applications
of what would be commonly considered as hygienic rules in the
treatment of disease would be to write a treatise on nursing, and
would also include a large part of the practice of medicine, for
regimen is the more important half of practical therapeutics. The
hygienic requirements peculiar to each disease will be pointed out by
the writers upon special subjects, and I shall only venture upon one
or two general remarks in addition to the hints already given in
speaking of the several causes.

In the acute stages of disease the sensations--or, if the term be
preferred, the instincts--of the patient are usually the best guide to
his regimen so far as they go. In most cases he desires quiet, shade,
but not absolute darkness, and little or no food, although there is
often a craving for drinks, especially of a cooling character. In the
specific fevers which have a tolerably definite period and course it
is important to keep up the nourishment even during the period of
anorexia, in order to provide against the debility which is to follow.
This nourishment is best given in the form of drink, and very
frequently fresh milk is the type of what is required. The old notion
that whatever a sick man desired must be hurtful, and therefore that
the fever patient must be kept hot and refused cool water, has now
almost entirely passed away.

In convalescence from acute disease and in many chronic cases, the
sensations of the patient are not to be trusted as a guide in the
choice of food. In such diseases as yellow fever and typhoid fever to
allow the convalescent to follow the dictates of his appetite is to
run great risk of a fatal result. In other cases the patient really
has no wish in the matter, but it {206} will often be found that one
who can think of nothing which he desires to eat, and who will even
refuse a dish which he has requested and been thinking about, will eat
with enjoyment some unexpected dainty when presented at the right
moment and properly served as a skilled nurse knows how to do. The
manner of serving the food, independent of its cooking, is not a
matter of such small importance that the physician can afford to
overlook it, and he will succeed best as a practitioner who best
appreciates the influence which cracked goblet, a chipped saucer, a
soiled napkin, or, on the other hand, a hot plate or a touch of color
in the shape of a leaf or flower, may have upon the capricious
appetite of the sick. In ordering diet for convalescence it is not an
uncommon error to select only those articles which are agreeable to
the physician himself, forgetting the old proverb, that what is one
man's meat may be another man's poison, and also that it is above all
things desirable to avoid monotony. One doctor always orders chicken,
another eggs, a third a mutton-chop, etc. The practice in this respect
has probably been unduly influenced by the reports of Beaumont of the
results of his observations on Alexis St. Martin, and we still find
that the relative digestibility of various articles of food is
estimated according to the scale laid down in these reports, with no
allowance for individual peculiarities, previous habits, mode of
cooking, etc. The secret of success in the diet of convalescence lies
mainly in the simplicity of the individual dishes, in varying the
different meals, in the manner of serving, and in carefully observing
the effects on the sick person, and being guided by the results.

To promote appetite and digestion, and to secure refreshing sleep, one
of the most important things is fresh air, but in many houses a sick
person will obtain but a very limited allowance of this if the
physician does not give special attention to the matter. Except in
cases of contagious disease, the rules for managing which have been
given in a previous section (p. 201), as soon as a patient is
sufficiently recovered to be moved for a short time into another room
his bedroom should be thoroughly aired and cleansed, and this should
be done morning and evening thereafter.

In treating cases of contagious disease the question often arises as
to means of individual prophylaxis to be used by those who must be
exposed to the effects of the infected locality or of the presence of
the sick. The attempts which have been made to secure this individual
protection in the midst of an epidemic have been numerous and varied,
ranging from the use of the "vinegar of the four thieves" of the
Middle Ages to the employment of the sulphites and chlorates to make
the blood unsuited to the growth and multiplication of the supposed
germs, or of cotton-wool respirators to strain the infected air, or of
supposed specifics for particular diseases, as belladonna for scarlet
fever and vaccination against small-pox. As yet, there is little or no
satisfactory evidence as to the value of individual precautions
against those diseases whose contagion is conveyed through the air,
small-pox alone excepted, but in case of diphtheria in one member of a
family of children it might be well to try the use of chlorate of
potash internally, combined with the local application of the tincture
of the chloride of iron, as suggested by E. M. Hunt. The question is
one to be investigated by careful observation and experiment; and,
though it is improbable that any definite results will be obtained
except in those diseases which are communicable to animals, and
therefore {207} susceptible of direct experiment, still, it is
possible that some advance may be made. In rare and exceptional
cases--as, for instance, in exploring a crowded, filthy, and intensely
infected typhus-fever nest, as a tenement-house, or an infected
yellow-fever ship--it may be worth while for the physician or
inspector who is unprotected by a previous attack of these diseases to
make use of a cotton-wool respirator, which is readily extemporized,
and belongs to that exceedingly valuable and popular class of remedies
which, "if they do no good, can do no harm." In epidemics of typhus,
cholera, or yellow fever one of the most valuable prophylactics is to
have a mind so occupied with other matters that it pays little or no
attention to the danger, while in case of small-pox fear of the
disease is indirectly the best prophylactic, since it leads to careful
vaccination.

This branch of the subject is closed with the remark that it would be
well if physicians, and especially the younger ones, gave more
attention to the preservation of their own health than many of them
do. The possession of a medical diploma does not prevent the evil
effects of irregular and hurried meals, insufficient sleep, exposure
to inclement weather, and lack of systematic and sufficient exercise;
and too much tobacco, sometimes too much alcohol, and in exceptional
cases too much study and literary work, so often combine with anxiety
about individual patients or with pecuniary worries to damage the
digestion and nervous system of the young practitioner that the wonder
is that so many survive the ordeal. And, in fact, the mortality among
physicians under the age of thirty is higher than that of any other
profession during the same period of life.


III. Public Hygiene in its Relations to Physicians.

An important difference between man and animals is found in the extent
to which he will sacrifice a present pleasure or convenience to secure
a future good or to avoid a future evil. The savage will do this to
only a very limited extent--little more, in fact, than the beaver or
the squirrel--and the lesson is learned but slowly and by sad
experience. This is especially the case as regards matters affecting
health. When a man begins to take special precautions as to his diet
or exercise, having in view rather his future health than his present
comfort and tastes, he has in most cases already begun to suffer from
the effects of his imprudence, and does not commence a hygienic course
of life as a perfectly sound and healthy person. The same is true for
a community. It will not usually submit to the burden of taxation
necessary to secure drains and sewers or a proper registration of
vital statistics, nor to the cost and inconvenience of the machinery
necessary to limit the spread of contagious diseases, until the
neglect of these things has resulted in such an amount of disease and
death as to forcibly call attention to the matter. The result is, that
the burden is far heavier than it would have been had the work been
undertaken in proper season, and individuals may find it to their
interest to leave the place and settle elsewhere rather than remain
and meet their proportion of the expense.

When a state or municipality has so far advanced in civilization as to
consider it desirable to take measures to protect the public health by
preventing individuals from polluting the air or water liable to be
used by {208} their neighbors, etc., the services of the medical
profession are always called upon. The foundation of public hygiene is
information as to the occurrence of certain forms of disease, the
cause of which can be referred with more or less precision to a
certain limited locality. This information may be very imperfect,
consisting of little more than rumor and opinions as to the existence
of an undue amount of sickness or mortality in a certain place, or it
may consist of precise reports setting forth the number of deaths from
each cause, the proportion of each of these to the population by age,
sex, occupation, etc., and of the whole to births--constituting what
is commonly called the "vital statistics of a place"--and also of
reports of the occurrence of certain preventable diseases; and between
these two the information may be of various degrees of completeness,
but, whatever there be, it is for the most part obtained either
directly or indirectly from medical men. The reliability and
completeness of the information thus obtained by the state determines
to a great extent the direction and character of the work done in
destroying or preventing the causes of disease, and it is also an
important means of increasing our knowledge with regard to the nature
of these causes.

The character of this information depends largely upon the character
of the physicians who furnish it. In a large part of the country
medicine is legally in the position of any common occupation; that is,
the term "physician" is defined as applied to "any one who publicly
announces himself to be a practitioner of this art, and undertakes to
treat the sick either for or without reward." Under such circumstances
there can be no guarantee that all who call themselves physicians are
properly qualified or competent to furnish reliable information for
registration purposes, and, as a matter of fact, a large number are
not so qualified. It is for this reason that there is such a close
connection between public health authorities, registration of vital
statistics, and the registration of those physicians whose
certificates as to causes of deaths, etc. will be accepted by the
state; and hence the nature of the public health organization of a
state and the personnel of its officials are matters of great
importance to physicians. On the other hand, the efficiency of a
public health service depends very largely upon the relations which it
holds with, and the light in which it is regarded by, the medical
profession. A health officer who is distrusted and disliked by the
physicians of his district cannot effect much unless he can overcome
this feeling, and his tenure of office must always be very insecure.

The official relations of the practitioner with the health authorities
are usually confined to the subjects of registration of vital
statistics and of checking the spread of contagious diseases. The most
marked exception to this rule is furnished by the States of Alabama
and North and South Carolina, in which the State Medical Society is
the State Board of Health, having been given legislative powers and
the right of selecting the health officers. The most complete
organization of this kind is that of the State of Alabama, where by
the act of 1875 the Medical Association of the State was constituted
the State Board of Health, and the county medical societies in
affiliation with the State Society were made county boards of health,
to be under the general direction of the State Board. These county
boards at first had advisory powers only, and were to be conducted
without expense to the State or the county, except that the competent
legal {209} authorities of any county might invest the county board
with such powers and duties for the promotion of the public health as
might be mutually agreed on; but in such case the right to elect or
appoint those employed in sanitary administration is reserved to the
board of health, while all questions relating to salaries,
appropriations, and expenditures shall be reserved to the legal
authorities. It was further provided "that no board of health, or
advisory or executive medical body of any name or kind for the
exercise of public health functions, shall be established by authority
of law in any county-town or city of this State except such as are
contemplated by the provisions of this act, the object of this
prohibition being to secure a uniform system of sanitary supervision
throughout the State." By an act of 1881 the county board is directed
to elect a health officer, who is to keep a register of the births,
deaths, and cases of pestilential or infectious diseases occurring in
the county, and furnish to physicians, free of charge, reliable
vaccine--to obtain information as to the sanitary condition of his
county, etc. etc. It will be seen that this plan of organization is an
attempt to overcome the practical difficulties in the way of obtaining
from physicians the information necessary for the registration of
vital statistics and the work of preventing the spread of infectious
diseases.

While the great majority of physicians are willing to furnish the
information as to the cause of death, etc. which is necessary for a
useful registration, there are always some who either neglect or
refuse to do so; and if the law be made compulsory, it provokes
hostility unless compensation is furnished, while as regards the
requiring physicians to furnish information as to the existence of
contagious diseases, this always rouses opposition on the part of a
certain number of medical men, even if payment for such notification
is provided. And while this opposition is no doubt in many cases due
to improper motives, such as personal hostility to the existing
authorities, party politics, or a desire for notoriety, its strength
nevertheless rests upon the fact that it is unjust for the state to
compel the services of any man or class of men without furnishing
compensation. The advocates of health and registration laws are thus
placed between Scylla and Charybdis: if they propose compensation,
which involves appropriations from the public treasury, the law cannot
be passed; if there is no compensation allowed, complete results
cannot be obtained.

The Alabama law makes compulsory the furnishing by physicians of
information relating to births, deaths, and infectious diseases, and
gives compensation--not in money, but by allowing the medical
profession to have the sole management of the matter and to choose the
health officers to whom they are to report; in other words, they are
allowed to tax themselves. The result in Alabama is yet doubtful. If
competent and faithful health officers and registrars can be obtained
without paying them a fair compensation, it will be contrary to
experience; and if these officers receive a salary, it will be strange
if the positions do not become the reward of partisan political work.

It should be noted that the requiring a physician to report the births
occurring in his practice stands on a very different basis from the
requiring him to report the cause of death, since there is no special
necessity for the former. It requires no expert knowledge to report a
birth, and the duty should obviously devolve on the householder.

{210} In those States in which by law only properly qualified medical
men, as determined by examination, have the right to practice, to hold
medical office, or to furnish medical certificates, the State
certainly is entitled to require of all physicians thus registered and
authoritatively recommended to the people as competent, that they
shall furnish, free of charge, certificates of the cause of death in
those cases where they are cognizant of such cause.

States and municipalities often demand much more than this; as, for
instance, that the medical man shall fill out the whole certificate,
including age, nativity, nativity of parents, etc., and that he shall
furnish the information to the registrar. In some cases it is provided
that any physician having attended a person during his last illness
shall furnish the certificate: this would apply to cases where the
physician may not have seen the case for weeks before death.

While it is most convenient to have the certificate of cause of death
upon the same form which contains the data necessary to identify the
individual, the certificate should be distinct from the latter, and
the duty of making the return to the registrar should devolve on the
householder or undertaker, and not on the physician. On the other
hand, it is easy for the physician to be hypercritical in these
matters: his certificate is to be considered rather as a statement of
opinion than as a statement of facts within his personal knowledge,
precisely as he would certify as to his own age and birthplace.

The compulsory notification of infectious diseases to the health
authorities is a matter presenting much greater difficulties than that
of certificates as to causes of death. The state has no right to
require such notification from the physician without giving some quid
pro quo, and it is not expedient to make it compulsory, even with
payment, except from physicians employed by the state or municipality,
to furnish gratuitous medical attendance to the poor. The state has
the right to require such information from the parent or householder,
and it has also the right to require the physician to notify the
parent or householder as soon as he recognizes the existence of such
infectious disease. It is extremely desirable that the health
authorities of a city should receive promptly, and direct from
physicians, notification of the occurrence of such diseases, and there
will usually be no difficulty in obtaining this if the health officer
has tact and discretion and the city is prepared to do its duty. This
duty is not confined to registering the information or placarding the
house, nor will it be properly performed by merely removing the sick
person to a hospital and disinfecting the premises. If the case occur
in a family which can secure its proper isolation, and the attending
physician certifies that it is so isolated and makes himself
responsible for its management (for which responsibility he should be
paid by the patient or his friends), the health officer should not
interfere nor do more than furnish a competent person to secure
disinfection if required. The employment of a trained nurse known by
the health authorities to be competent and reliable would do away with
most of the difficulties connected with such cases in the upper and
middle classes of society; and such nurses should be registered just
as physicians and midwives are.

Where the case cannot be thus isolated and properly cared for, it
should be removed to a proper hospital. This presupposes that the city
has such a hospital, and if it has not, and is not prepared for such
cases, notification {211} is useless. When the city places a house in
quarantine so as to interfere with business, it should be for the
shortest possible time consistent with securing thorough disinfection
of the premises, and the city should bear not only the cost of such
disinfection, but the cost of caring for the persons in the house in
an isolated place until no further danger is to be apprehended for
them. When the city undertakes to pay all expenses for isolation and
disinfection of such cases, it has the right to require that all such
cases shall be so treated, leaving it to private parties to meet the
cost in case they prefer not to use the buildings and apparatus
provided by the city for that purpose. And when the city does its duty
in this respect, it will be found that physicians and the people will
do theirs, with rare exceptions.

When a city becomes very unhealthy the usual policy is to conceal the
fact as much as possible, and to attribute the mortality to some other
than the real cause. The influence of the mercantile part of the
community is in such a case strongly exerted on the daily press and on
the health authorities to produce such representations of the
condition of things as will tend to allay apprehensions on the part of
their customers. The healthfulness of a place is usually estimated
from its mortality reports, but the reliability of these is by no
means always what it should be. Yellow fever is called typho-malarial
or pernicious fever, typhoid is reported as diarrhoea or malarial
fever, etc. etc., and great stress is laid upon what is called the
sanitary condition of the place, which is declared to be excellent.

Unfortunately, this phrase, "sanitary condition," means different
things at different times. When the mortality is low, sanitary
condition means the healthfulness of a place; when it is high, it
means the cleanliness of a place. To a certain extent physicians are
responsible for the truth of the statistical returns, not so much in
relation to the number as to the causes of deaths; but none save those
who have practised in a city liable to epidemics can realize the
enormous pressure which is brought to bear on medical men to induce
them to aid in or wink at concealing the true state of the case. Of
course, this ostrich-like policy is in the long run an exceedingly
unwise one, but neither the average householder nor community can be
expected at present to pursue any other, except under pressure.

There are many questions as to the best form of public health
organization, and the powers and duties which should be conferred upon
it, which can only be properly answered by taking into consideration
the circumstances in each case. In a large city the health officers
must have great powers if they are to be really efficient. They have
to contend with ignorance, custom, and self-interest, and their action
must in many cases be prompt and unrestricted if it is to be
efficacious. They must sometimes be in conflict with wealthy and
powerful corporations, whose interests are opposed to the reforms
which they urge, and although their business is to protect the most
important interest of the community at large--_i.e._ its
health--against the interests of individuals, yet these last are much
more immediately concerned, and are, naturally, so active that they
are often, although few in number, able to defeat any attempt to
interfere with their occupations.

It not unfrequently happens that a health board may have all the power
{212} necessary, so far as the laws are concerned, and yet may be able
to accomplish little for want of funds to pay the inspectors and other
officials whose services are necessary. For a city, a health officer
usually does better work than a board of health: his responsibility is
more direct, and he has stronger motives to do good work, than a
board. Of course, a poor health officer is less efficient than a good
board of health, but the general rule is as above stated. The problems
of hygiene require special knowledge, and the man who is to deal with
them requires special training. The folly of treating diseases by
their names with popular or patent remedies is not greater than that
of the attempt to make a healthy house or city by men who are not
architects or engineers or physicians, or who have only the
information possessed by the average architect or engineer or
physician. And, of all professional or educated men, the physician
especially should recognize his own ignorance. When he is asked what
one should take for dyspepsia or pneumonia his answer is, "Take the
advice of a physician;" and so when he is asked how the plumbing of a
house should be arranged, how a hospital should be ventilated, how a
city should be sewered, how a marsh should be dealt with or a
water-supply provided, he should reply, "Get expert advice and
supervision, and be prepared to pay the amount necessary to secure
it." It is the special duty of the physician to exert his influence to
secure properly constituted sanitary authorities for his own locality,
his State, and for the nation, and to support these against the
hostility which they must inevitably arouse if they are efficient. And
he should do this, not blindly and as a partisan, but intelligently
and with due consideration of all the important interests involved.

The body of educated physicians in a community forms the tribunal by
which the work of sanitary officials is to be judged, and they cannot
judge wisely unless they appreciate the difficulties with which health
officials have to contend. If a city has an incompetent or dishonest
board of health, the medical profession of that city are to a certain
extent responsible for it; if a competent, energetic, and faithful
sanitary officer is crippled and harassed or forced out of office
because he is on the wrong side of politics, or because in the
legitimate and proper exercise of his functions he has come in
conflict with the interests of powerful and wealthy individuals or
corporations, it is the duty of medical men to support him, and to do
this actively and promptly. And I take great pleasure in being able to
say, as the result of somewhat extended observation, that, as a rule,
the physicians of this country do cheerfully and promptly co-operate
with the sanitary authorities where such exist, and are the first to
try to have them properly organized and given the necessary means and
powers to do effective work.



{213}

DRAINAGE AND SEWERAGE IN THEIR HYGIENIC RELATIONS.

BY GEO. E. WARING, JR.


For reasons, sometimes sound and sometimes fanciful, the drainage
question often presents itself to the medical practitioner as an
annoying if not as a serious one. It is not necessary for the
physician to make himself an adept in the art of sanitary drainage,
but he can properly meet neither the demands of nervous patients nor
the exigencies of sometimes serious situations without having an
intelligent general idea concerning it. Not only to prescribe
improvement, but frequently to allay ill-grounded apprehension, he
should be able to address himself, intelligently and promptly, at
least to the few simple problems presented in connection with ordinary
houses. I use the expression "ill-grounded apprehension," not because
the drainage in and about houses is generally tolerably good, for it
is not, but because the race seems to have so inured itself to certain
grave defects in plumbing-work that one may reasonably hesitate, and
look elsewhere for the occasion of diseases before accusing the
imperfect sanitary appliances of an average house.

Anything like a treatise on the technical details of house-drainage
would be quite out of place here. There are note-books easily
accessible to such physicians as care to make a thorough study of the
subject. It does seem worth while, however, to pass in careful review,
in a work of this character, the various conditions of interior and
exterior drainage upon which a physician is frequently called to pass
judgment.

The perfect drainage of a house, like the perfect drainage of a town,
implies the immediate and complete removal, to a point well beyond its
limits, of all waste matters which are a proper subject of
water-carriage; such a thorough ventilation of the channel which these
matters have traversed as to reduce to a minimum the production of
deleterious gases arising from the decomposition of the film with
which they may have soiled the walls of their conduit; and adequate
provision for the absolute and permanent exclusion from the atmosphere
within the house of the air of the pipe or sewer. This is a brief and
simple statement of the fundamental and absolute requirements of all
good drainage. It is founded on the one grand object which governs all
improvement of this character: the prevention of decomposition of
refuse matters anywhere in house or town.

Practically, it is safe to say that these conditions are never
complete, and that instances of perfect work are so exceptional as to
need no {214} consideration here. We have to assume, substantially in
every case that is presented, that we are dealing with defective work,
ordinarily with work that is very seriously defective. Most houses
have been built by contractors, and the plumbing is perhaps the item
of the whole structure that it is considered easiest and safest to
scamp or to neglect. Even where the motive of economy has had no
controlling influence, the drainage has almost invariably been planned
by a plumber who has learned his trade and conceived his ideas in the
performance of work which was done at a time when no one realized the
serious consequences of its being improperly done. The absence of
interior ventilation, leaky joints, ill-arranged connections between
the various plumbing appliances and the main outlet from the house,
pipes and traps so large that an ordinary current is powerless to keep
them clean, defects of form, defects of material, and defects of
construction, are met with on every hand. This general statement is of
itself sufficient to show how hopeless it is for the average physician
to prescribe the manner in which the drainage of a house should be
constructed or remodelled.

If we view the question solely with reference to its bearing on the
causation of disease, we enter a field where neither the sanitarian
nor the physician is ever sure of his footing. The precise relation
between bad drainage and ill-health no man knows. Certain diseases are
undoubtedly traceable to conditions of air or of drinking-water due to
the improper disposal of organic wastes, but the extent and exact
bearing of these influences are still greatly a matter of conjecture.
It is, however, undoubtedly safe to assume--and the assumption is
supported by ample general observation, if not by precisely
ascertained facts--that whether we are considering serious diseases or
the slighter ailments, every argument leads to the enforcement of the
most strenuous requirements of cleanliness. Through all the ages no
one has disputed, and no one has improved upon, the simple sanitary
formula, "Pure air, pure water, and a pure soil." We may safely wait
until the enthusiastic investigators now engaged with the subject
shall have adduced the testimony of positive facts, if we will in the
mean time adhere strictly to the requirements of Hippocrates'
prescription. The physician will surely not go wrong if he treats all
obvious defects of drainage as positive evils, and insists upon their
complete reformation.

Not to confine ourselves to houses which are provided with the
ordinary modern plumbing-works, but to include all collateral branches
of the subject, we have to consider the following conditions:

  I. THE REMOVAL OF HUMAN EXCREMENT:
      (_a_) By water-carriage in houses provided with modern plumbing;
      (_b_) By some form of dry conservancy;
      (_c_) By the fiendish privy-vault which prevails so generally,
              save in the larger cities.
 II. THE REMOVAL OF LIQUID HOUSEHOLD WASTES:
      (_a_) By delivery to public sewers;
      (_b_) By irrigation disposal;
      (_c_) By delivery into cesspools.

Incidentally to the above there must be considered the influences of
the ultimate disposal of all household waste, whether by the public
sewer or the private house-drain.

{215} I. THE REMOVAL OF HUMAN EXCREMENT.--We are too apt to judge of
the power for mischief of any waste matter by its original
offensiveness, and the world at large regards the solid and liquid
exuviae of the human body as the most dangerous material with which it
has to deal. Doubtless it is so under certain exceptional
circumstances. If impregnated with the infective principle of cholera
or of typhoid fever, for example, its influence for evil may be
widespread and active, but in the absence of such infection these
substances offer a less serious problem, and, as their offensiveness
causes them to be more carefully avoided, their evil influence is
less, and is less widely disseminated, than is that of the
comparatively inoffensive wastes of the kitchen-sink. This is a
consideration important to be borne in mind. Nothing is more common
than the expression of the opinion that the wastes of a population are
offensive and dangerous in proportion to the degree to which
excrementitious matter is allowed to flow away with its general
drainage. The fact is, that the drainage from a house or from a town,
if reasonably diluted with water, is very slightly offensive until it
has passed through a considerable degree of decomposition. The outflow
of a perfectly sewered town, where the whole community uses
water-closets, is less offensive than the neglected back-yard drain of
an average New England farm-house. The trouble begins with the
condition of putridity. Fecal matter and urine are somewhat quicker
than the other wastes of the house to enter into putrefaction, but the
difference is only one of degree, and the latter rapidly overtakes the
former in the foulness of its condition; so that where a house is
provided with two cesspools, one for water-closet matter and the other
for kitchen waste, it is quite impossible to determine from the
character of their contents which is which; therefore examinations of
the drainage of a house should by no means be confined to the manner
in which its excrementitious matters are disposed of. Setting aside,
in this connection, the peculiar liability of these matters to become
the seat of specific infections, it is fair to assume that equally
complete and cleanly arrangements are needed for all else that flows
to waste, as for the discharges of the water-closet. The purpose of
these remarks is of course not to belittle the importance of proper
care in the disposal of human excreta, but to prevent the giving of an
undue importance to this branch of the subject, with too light
treatment of the very serious difficulties presented by the others.

(_a_) Modern conveniences may fairly be said to be the bane of modern
society, or at least of such of its members as have the questionable
good fortune to be housed within the same four walls with every device
that a misguided talent for invention has led the American mechanic to
provide for the comfort and convenience of the occupant. Properly
regulated, there is no element of modern house-building more conducive
to health than such a system of plumbing as brings within reasonable
limits the labor of supplying abundant water at every point in the
house, and obviates the need for exposure and removes the temptation
to neglect and postponement attending the use of out-of-door houses of
convenience. The spigot and the water-closet are the two essential
sanitary agents which the plumber offers to us. The bath may be
replaced by the sponge, the stationary wash-basin may be, and
generally should be, replaced by the bowl and pitcher of our fathers,
but there is no sufficient {216} substitute for an ample supply of
water on each floor of the house and for a cleanly water-closet placed
within doors. The evil that the plumber has inflicted upon the race is
due very largely to his not having held his hand when he had fairly
provided for our reasonable requirements. When he fills our bedrooms
with stationary basins, connects our refrigerators with the sewer,
provides twenty outlets for water which had better reach the drain
through less than half that number, and incidentally underlays all our
floors with pipes, every foot of which is a possible source of danger,
he turns what ought to be a blessing into what is too often an
unmitigated curse.

It will not be easy to convert persons who have become accustomed to
the universal diffusion of plumbing-works throughout the house to a
belief that their best sanitary interest, and, perhaps hardly less,
the best requirements of refinement, point to the abandonment of what
is practically superfluous in the way of wash-bowls, bidets,
foot-baths, sitz-baths, urinals, etc.; but one who has given careful
attention to the subject cannot hesitate to recommend that in a house
which is "strictly first class" it would be the part of wisdom to
reduce by at least three-fourths the openings which lead to the
soil-pipe and drain and sewer, and to concentrate upon the remaining
fourth the flushing effect of wastes which are now so widely
distributed. Strenuous effort is being made, not only by those who
write and talk in the interest of the plumber and manufacturer, but by
many who honestly believe that the good the plumber has to give us
cannot be given with too free a hand, to prove that so long as they
are properly constructed and properly arranged we may use plumbing
appliances at every point in the house with the utmost freedom and
with a minimum of danger. The minimum of danger, and often more than
the minimum, does, however, exist. It exists, perhaps, in a constantly
increasing degree with every extension of the work, and it can only be
the part of wisdom to insist, so far as advice can have influence, on
the reduction of all these appliances to the least requirements of
reasonable comfort and economy of labor. My own advice would be, in
all cases, to permit the use of no wash-bowl or bath or other vessel
at a greater distance than a few feet from a vertical soil-pipe, and
not to permit their use in any case in bedrooms or in closets opening
only into bedrooms.

At the risk of seeming extravagant, I would say that the stationary
wash-bowl as ordinarily used is one of the most uncleanly of modern
household appliances. Long experience in the inspection of houses and
in the examination of waste- and drain-pipes has led me to the belief
that servants, by no means rarely, use these vessels as the most
convenient means of voiding and cleansing chamber utensils. Their
overflow-pipes are coated with soap and with the exuviae of the skin
to a degree which makes them usually the seat of an offensive
decomposition. Their plugs and chains are almost invariably foul, and
those devices which provide for closing the outlets by valves or
plugs, somewhat removed from the strainers at the bottom of the bowl,
bring the water in which the face is washed into an interchanging
communication with a considerable length of foul and uncleanable
waste-pipe--a communication that is made active by the bubbling of the
contained air as the pipe fills with water. The labor of filling
pitchers from a spigot on the same {217} floor, and the labor of
emptying chamber-slops into a water-closet on the same floor, are not
to be considered as compared with the greater cleanliness and the
greater sanitary security that such an arrangement ensures. There is
no serious objection to the placing of wash-basins and baths in the
same apartment with the water-closet, or elsewhere immediately
adjoining the soil-pipe; but it certainly cannot be disputed that the
extension of the drainage system by horizontal lead pipes to remote
points is altogether and wholly to be condemned.

However, the question more immediately at hand is that of the disposal
of human excreta by the use of water-closets; and it is the
water-closet that first attracts the attention of one who is called
upon to examine the sanitary condition of the work. There are several
radical defects in water-closets, which are so widespread and which
have become so familiar to the world at large as to attract less
attention than they deserve. For example, it is a radical defect of a
water-closet to be tightly encased in carpentry. Nearly all the
water-closets now in use have a somewhat complicated mechanism about
their bowls. They consist in part of earthenware and in part of iron,
generally with an unstable connection between the two. More often than
not they overflow or drip or leak, and whatever may escape from them,
whether foul air or foul water, is confined within an unventilated
space, but a space which is still not absolutely excluded from the
atmosphere of the house. The removal of the "riser" or vertical board
under the front of the seat will usually disclose at once a condition
that suggests at least the need for thorough ventilation. It also
discloses in some cases a complication of machinery and pipes and
levers and chains which makes a thorough dusting and cleansing of the
space difficult, even were it accessible. There are water-closets
which are essentially good in their construction and working, which it
is important to protect by a "riser," but this "riser" should never be
of close work. It should at least be freely perforated with large
holes, or, better still, be made with slats or blinds, so that there
may be the freest possible circulation of air under the seat. If there
is an entire absence of machinery, so that the whole space may be left
open, being well finished with tiles or hard wood or other suitable
material, it is better that it should be unenclosed and that the seat
should be hung on hinges, so that it may be turned back, exposing the
whole space to easy cleansing. It is better too, in all cases, that
the ventilation should not even be interfered with by a cover over the
seat, the freest possible exposure to the air being of great
importance.

A very large majority of the water-closets in use throughout the world
are either very imperfectly flushed "hoppers," which are generally
foul and which are often defective in their traps, or that worst of
all forms, known as the "pan" closet, where a slight depth of water is
held in the bowl by a hinged pan closing over its outlet. This pan
swings in an iron chamber under the bowl, which is entirely cut off
from ventilation, which is generally foul with adhering fecal matter,
and which as an abomination has no equal in the whole range of
plumbing appliances. The closet of which it forms a part has
everything to condemn it, and only its cheapness and its apparent
cleanliness, and the habit of the world in its use, to commend it. If
flushed, as it usually is, by a valve on the supply-pipe, it is rarely
flushed adequately, and its use not seldom leads to an indraft {218}
of foul air (or worse) into the main water-supply system of the house.
Such closets may be easily inspected as to their condition by shutting
off the water-supply, opening the pan, and lowering a candle into the
container below. Such an inspection will almost invariably disclose an
extremely and dangerously filthy condition. Yet the worst part of the
container, that which never receives an adequate flush, is even then
concealed from view by the pan being thrown back against it. The nose
will here be a good adjunct to the eye, and the odor escaping from
this filthy interior chamber will generally afford convincing
testimony of the impropriety of allowing such a vessel to remain in
use.

It is a rule almost without exception that closets, except perhaps on
the first floor of the house, which are flushed by valves connected
with the bowls, are to be condemned. However good or however bad the
state of a closet thus supplied with water, its condition will always
be improved by giving it a copious flush from an elevated cistern
delivering never less than two and a half gallons of water at each
use, and delivering it through a pipe so large and so direct as to
secure a thorough cleansing at every discharge.

It would be out of place here to enter into a detailed description of
the various closets which are and which are not to be recommended for
use. So far as the physician's inspection is concerned, it is perhaps
sufficient to say that wherever an odor, however slight, can be
perceived, and wherever a fouling of the interior surfaces of the
closets or of the spaces under the seat can be detected by the eye,
radical reformation is necessary. The only safety with a water-closet,
as with any other vessel connected with the drainage of the house, is
to secure an immediate and complete washing away of all foul matter of
every kind. Where this result is not attained, it should be insisted
upon. This much lies within the province of the medical attendant; the
manner in which it shall be secured is not necessarily for him to
decide.

One other branch of this subject is worthy of attention. The
cleanliness and freedom from offence of the water-closet or of a
waste-pipe or drain is in proportion to the frequency with which it is
used and to the abundance of the discharge of water through it. A
dozen closets used by a dozen persons will be quite likely all to be
offensive. If the dozen persons all used only one closet--not a pan
closet--the frequency with which its trapping water is removed and the
frequency with which its walls are washed would secure its tolerable
condition, even if not of the best construction. In this case, as in
all others, simplicity should be the controlling principle.

(_b_) Dry conservancy next after water-carriage is the best and safest
system for the removal of human excreta. By dry conservancy is meant
the admixture of dry earth, ashes, or similar material with the
matters to be disinfected and absorbed. Theoretically, the effect of
such admixture is entirely satisfactory; under very careful and
intelligent regulation it is practically so. It has been proved,
however, by much experience that under ordinary circumstances--that
is, where no greater care is given than is ordinarily given to a
water-closet or to a common privy--the dry conservancy system is open
to serious objections, though always an improvement on the cruder
privy-vault. The theory of the effect of a sufficient admixture of
earth or ashes with urine and fecal matter is, that by the {219}
admission of air thus secured to every part of the material there is a
complete oxidation of their organic constituents, similar to, though
slower in its operation than, actual combustion in an active fire. In
isolated houses and in hospitals, factories, and other buildings not
provided with sewerage facilities, there is no question that the
earth-closet or the ash-closet affords the best available means for
disposal, if we except a system, to be described hereafter, for the
distribution of water-carried wastes over or under the surface of
suitable ground.

Incidentally--and this is of special interest to the physician--the
use of dry earth or of dry ashes in the close-stool of the sick
chamber effects not only an immediate and complete deodorization, but
without doubt a complete disinfection as well. A quart of dry earth at
the bottom of the vessel to receive the deposits, and rather more than
a quart with which immediately to cover them, constitutes a means of
relief always available and always efficient.

Where the house is provided only with an old-fashioned out-of-door
privy the greatest relief and the most complete security may be given
at little cost by filling the vault, and placing under the seat a
movable box to receive the mixture of fecal matter and of the
absorbent material, which, if it is desired to avoid the simple
patented appliances made for the purpose, may be kept in a box or
barrel in the apartment and thrown down after each use of the closet
with the hand-scoop. The objections to the common privy are so
obvious, so universal, and so well understood that the practical value
of such a means of relief should be appreciated without argument.

(_c_) Privy-vaults are the sole reliance for the disposal of fecal
matter, and often of chamber-slops, of probably 95 per cent. of the
population of this country, and of Europe as well. It is curious, in
examining the recommendations of public health officers and the
requirements of local boards of health, to observe the uniformity with
which this most important subject is passed over with the prescription
that the vault shall be tight, sometimes that it shall be vaulted
over, and sometimes that it shall not be within a certain small number
of feet of a boundary-line or of a drinking-water well. These
prescriptions are most absurd. It is safe to say, that of the millions
of privy-vaults in this country not more than hundreds are really
tight; that a still smaller number are so vaulted over as to prevent
the free exhalation of the gases of decomposition; that those which
are so vaulted over are in all respects of worse sanitary effect than
those which have freer communication with the air, and that their
possibilities of evil reach many times farther than the limits of
distance usually required to intervene between them and the well or
the neighboring property. In view of the universality of their use and
of the completeness with which modern communities are inured to their
presence, it seems almost hopeless to attempt to secure a proper
realization of their great defects. They are always the seat of the
foulest, and even of the most dangerous, decomposition. They taint not
only the air and the soil, but the water of the soil which goes so
often to feed our sources of drinking-water, and their local stench is
of itself sufficient to sicken all who have not by daily and lifelong
habit become accustomed to it. Taking the country at large--farm
houses and village houses as well as the dwellings of cities--it is
not too much to say that the best sanitary service that {220} can be
rendered by those interested in the removal of causes of ill-health
would be in securing the abolition of these barbarous domestic
appliances. In many ways the cesspool is as bad as the vault, but in
some respects the vault is facile princeps as a public and private
nuisance of the most annoying and dangerous character. Wherever a
public or private sewer is available, wherever disposal by irrigation
is possible, and wherever even the crudest attention can be secured
for an automatic or simpler earth-closet, the strongest effort should
be directed to the absolute inhibition of the common privy-vault.

II. THE REMOVAL OF LIQUID HOUSEHOLD WASTES.--As has been stated above,
the liquid household wastes are of much more serious consequence from
a sanitary point of view, as compared with excrementitious matters,
than the public has been wont to suppose. These, owing to the large
amount of water which they contain, are beyond the reach of any system
of dry conservancy. They consist almost invariably of a flood of water
containing but a small percentage of refuse food, urine, soap, filth
of the laundry, grease--everything, in fact, except fecal matter and
the coarser garbage and ashes--constituting the waste of the
household. Where water-closets are used fecal matter is generally
added to the flow, but its relative quantity is small, and its
presence or absence does not seriously affect the problem of disposal.

In a house provided with abundant, generally superabundant, plumbing
appliances, with a large consumption of water, the whole apparatus is
constructed on the theory that all manner of filth is to be taken up
by running water and carried well without the house. Where this
theoretical end is completely attained there exists a condition of
drainage rarely met with and little to be criticised. Unfortunately,
the theoretical excellence is rarely secured. Running water confined
within a narrow channel, and so compelled to move with force
sufficient to give an energetic scouring to the walls of its conduit,
may be trusted to carry with it or to drive before it pretty nearly
all foreign matter that may have been contributed to it, but the
moment this vigorous current is checked, that moment the tendency to
excessive deposit begins. It is checked in practice in various ways:

First. By too great a diameter of the pipe: a volume of discharge
requiring a velocity of 4 feet per second in a pipe 1 inch in diameter
would have a velocity of only 1 foot per second in a channel 2 inches
in diameter, and of less than 6 inches per second in a channel 3
inches in diameter. Ordinarily, except as the deposits are removed by
decomposition (always objectionable), the deposited matters accumulate
and reduce the original bore to the diameter which will secure a
cleansing flow. It is the part of wisdom to provide only this bore at
the outset or not greatly to exceed it, and it is one of the earliest
recommendations of an experienced sanitary engineer to reduce the size
of too large bores where they exist.

Second. By the use of traps larger than the pipes leading to them and
from them, thus increasing the natural tendency of all traps to
stagnation and deposit.

Third. By the use of vertical waste-pipes, which are almost universal,
and which are very often necessary. The velocity of a current measured
along the axis of the pipe is less if the direction is vertical than
if it is laid on {221} a steep slope, because of the tendency of
liquids flowing through vertical pipes, which they do not fill, to
adhere to the walls and to travel with a rotary movement. I have seen
vertical soil-pipes furred with excrement to a thickness of nearly
three-eighths of an inch; I have never seen a corresponding deposit in
a pipe of good slope where the current was direct. This latter point
is rather one of curious interest than of practical value--certainly
from the physician's point of view. Even in original construction it
is rarely possible to give soil-pipes other than a practically
vertical course as they pass from one story to the next. Indeed, the
physician need not trouble himself to consider the question of the
size or of the direction of this main channel. He will often find
occasion to criticise the use of unduly large waste-pipes from single
vessels; as, for example, two-inch pipes leading from bath-tubs; two
and a half-inch pipes leading from laundry-tubs; and three-inch pipes
leading from kitchen-sinks. Where reconstruction is to be undertaken,
he may with advantage exert himself to secure in these lateral
waste-pipes a diameter never exceeding one and a half inches, and from
kitchen- and pantry-sinks, whose outflow is loaded with grease,
preferably not exceeding the diameter of one and a half inches, with
traps of even a little less size. Where several vessels lead into the
same waste-pipe these small diameters may increase the tendency to the
emptying of the traps by siphonage, but if proper mechanical traps are
used for baths, wash-bowls, and laundry-tubs, and if ample flushing
appliances are connected with kitchen- and pantry-sinks, the temporary
removal of the trapping-water by siphonage may generally be
disregarded. It will seldom happen that the removal of water will be
so complete as to prevent the satisfactory closing of the mechanical
valve by capillarity, even if it fails, in itself, to make a perfectly
tight fit.

A favorite recent requirement of theoretical sanitarians, and one
which has perhaps for business reasons been eagerly accepted by the
plumbing trade, is what is called the "back" ventilation of traps;
that is, the carrying of a vent-pipe from every trap in the house to a
point above the roof. In my judgment, there is more to condemn than
there is to commend this practice, for I believe that the more rapid
emptying of traps by evaporation where they are not constantly
supplied by frequent use, the dangers of accident to lead pipe, which
is generally used for ventilating purposes, and the misapplication of
a large outlay which might better be applied in other directions,
constitute convincing arguments against this favorite new method of
preserving the integrity of the water-seal. There are a number of
traps which are closed by floating balls, or by balls bearing upon the
outlet, which seem to be quite satisfactory and efficient. The worst
waste-pipes, by far, are those of kitchen- and pantry-sinks which pass
a large amount of hot grease. This soon cools sufficiently to congeal,
and it attaches itself to the walls of the pipe, where it does congeal
until the bore is reduced to what is barely sufficient to furnish the
necessary limited water-way. Grease-traps of various forms have been
invented with a view to retaining this obstructing material. After
much experience with all of them that have been in general use, I have
become convinced that the only satisfactory way to avoid the
difficulty in question is to retain the outflow of the sink until a
certain considerable quantity has accumulated, and until its grease
has entirely {222} congealed, then to discharge the whole volume
rapidly through a pipe of small calibre. This may be done with
Carson's grease-trap by throwing in a pail of water to start a siphon
action when the vessel has become filled to its overflow-point. It is
more simply accomplished by a device of my own, wherein the whole
outflow is retained by a plug at the bottom of a large vessel working
after the manner of the plug of a wash-basin, until it is filled to
the level of the sink, and then opening the outlet for its sudden
discharge.

Good workmanship is as important as, if not indeed more important
than, good arrangement. It seems a very simple proposition to say that
all waste-pipes, whose office it is to carry foul liquids out of the
house, should be made tight in material and in joint. It is a
remarkable fact, however, that leaky joints in soil-pipes and in
drains are by no means rare. Probably there are few houses, very few,
in which they do not occur. The soil-pipe is put together by inserting
the small end of each section into the bell at the top of the section
below it, practically like putting the outlet of one funnel into the
larger upper portion of another. There may be abundant space for
leakage at every joint from the top to the bottom of the house,
without there being the least show of the leakage of water. The foul
air within the pipe may escape freely through a dozen openings, while
the heavier liquid flow takes its easiest and most direct course
downward from the point of one pipe through the bell of the one below.
When we come to the horizontal run of the soil-pipe in the basement,
if an imperfection of the joint occurs on the lower side there is an
obvious drip, which continues at least until closed by rust. Similar
imperfections in other parts of the joint would not be so manifested.
It has recently been demonstrated that there is no safety in the
construction of soil-pipes short of that absolute assurance which can
be secured only by an efficient test. Plugging all the outlets of the
soil-pipe and filling it with water, the slightest leak will be
exposed.

However defective may be the condition of an iron soil-pipe, vertical
or horizontal, it is perfection itself compared with the usual state
of a drain laid under the cellar floor; and here is a point where the
least experienced inspector of house drainage cannot be mistaken.
Under all circumstances, at least in all work hitherto executed, he
should demand as absolutely necessary that the drains under the cellar
floor be removed, that the earth which has been fouled by the leakage
of its joints and its breaks shall be taken out to the clean untainted
soil below, and refilled with well-rammed pure earth or with concrete,
the drainage being carried through a properly-jointed iron pipe above
the pavement, and preferably with a fall from the ceiling of the
cellar to near the floor at the point of outlet--in full sight for the
whole distance. It sometimes happens that the necessity for using
laundry-tubs or other vessels in the cellar makes the retention of an
underground course imperative. When retained, the drain should be of
heavy cast iron with most securely leaded joints tested under a head
of several feet. When found to be tight and secure, it should not be,
as ordinarily recommended, left in an open channel covered with boards
or flags and surrounded by a vermin-breeding, unventilated and
uninspected space, but closely and completely imbedded in the best
hydraulic cement mortar. Its careful testing before this {223}
enclosure is of course the only condition under which the work can be
permitted.

Tightness of all waste-pipes being secured, the next point in order is
their proper ventilation. A good deal has been said, and little has
been proved, about the different effects on the human system of the
gases of decomposition which have been produced in the absence of a
sufficient circulation of air, and those produced where the
ventilation and dilution are more complete. The probabilities of the
case are, of course, entirely in favor of the latter condition, and it
is accepted by all sanitarians as an axiom that all water-ways and all
vessels in which organic decomposition, even the decomposition of
adhering slime, takes place, should be ventilated as thoroughly as
possible. Until about ten years ago nearly all waste-pipes were
tightly closed at the top, and were shut from the sewer by a trap at
the foot, allowing absolutely no communication between the outer air
and the atmosphere of the pipe except as fresh air might be carried in
through the water-seals of the traps at each end. At about that time
it was becoming the general custom in the better class of work to
carry a small vent-pipe, often only one inch in diameter, rarely more
than two inches in diameter, through the roof of the house, closing it
at the top and perforating it with a few inefficient holes. This had
undoubtedly the effect of relieving the pressure on the atmosphere of
the pipe caused by the filling of unventilated sewers with tide-water
or storm-water, or by a sudden increase of temperature from the
admission of hot water. Later, it was accepted as a universal rule,
and it became a quite general practice, to carry the soil-pipe above
the roof with its full diameter, providing its summit with some form
of ventilating cowl. All this constituted not ventilation, but
venting. Real ventilation was introduced only with the very recent
improvement of admitting fresh air at the foot of the soil-pipe, so as
to make a complete circulation from one end to the other--a
circulation sufficient to produce, by the diffusion of gases, a very
fair ventilation of lateral waste-pipes of moderate length. It is now
coming to be understood that ventilating cowls, of whatever form, are
an obstruction to the movement of air in the absence of wind, and
that, as what is needed is never a vigorous current, but always a
living one, these cowls had better be dispensed with. We have learned,
too, that the most efficient means for increasing the flow of air
through the top is to increase its diameter at the top, enlarging the
highest length of a four-inch pipe, for example, to a diameter of six
inches. With this arrangement, and with a foot-ventilation four inches
in diameter opening at a point where it can never be obstructed by
rubbish or by snow, there will be secured a condition perhaps more
efficient in improving the condition of an imperfectly drained house
than any other one thing that may be done.

I have sketched above, in a very hurried manner, the main outline of a
system of house-drainage which may be accepted or which may be
recommended by a physician with confidence of securing a good result.
To go more into detail in technical matters would be out of place in a
paper of this character. Before leaving this subject, however, it is
important to call attention to the fact that what is recognized in our
houses as sewer gas is in far greater degree the product of
decomposition taking place within the house-drains themselves than the
product {224} of decomposition in the distant sewer forced into the
house through its connecting drain. It is emphatically a case of the
beam in our own eye as compared with the mote in the eye of our
neighbor. It is a rule which has exceptions, but they are few, that
the contained air of the house-pipes is far worse than the contained
air of the sewer; and the conviction is growing that the use of a trap
to the main drain between the house and the public sewer is more often
objectionable than advantageous. Such a trap always tends to check the
flow of the drain and to induce deposits whose decomposition is
objectionable. Wherever the abandonment of the trap is anything like
universal the considerable ventilation of the sewer thereby secured
brings its atmosphere to a condition which makes it not objectionable,
and generally useful, as a source of movement in the air of the
interior drain- and soil-pipe.

(_a_) Public sewers are more or less good or bad entirely according to
their character and condition. As a rule, a well-flushed sewer which
is used for no other purpose than the removal of foul waste, built on
what is called the separate system, and automatically flushed at least
daily, may be considered to be, if well laid and tightly jointed,
absolutely safe. A public sewer of large size and of irregular
construction, receiving not only household wastes, but the wash of
streets as well, may be regarded at least as an object of grave
suspicion. These general statements may be so far qualified by the
character of the sewers of each class as to run very nearly together;
that is to say, separate sewers, with leaky joints, irregular grades,
defective alignment, insufficient flushing, and inadequate restriction
as to the matters they are to receive, will be an intolerable and
dangerous nuisance; on the other hand, a large brick sewer built in
the best manner and of the best material, with sufficient fall and
sufficient supply to maintain itself in a cleanly condition, is free
from the serious drawbacks which usually attach to sewers of this
class.

With sewerage as with house-drainage it is not worth while to attempt
here to give anything like detailed directions for inspection and for
reformation. It will suffice to call attention to this one broad and
general rule: Every sewer or drain having for its object the removal
of putrescible organic matters must be so arranged as to maintain
itself in a condition of practically absolute cleanliness, without, as
in the case of storm-water sewers, waiting for the flushing effect of
storms, which often come only at long intervals, during which the
worst condition of decomposition may be established. Whether the sewer
be intended for drainage only or for both drainage- and storm-water,
if it contains at any time deposits of any kind, it is defective--more
or less so, of course, according to the extent and duration of the
accumulation.

Although it should be rigidly insisted upon in every case that the
sewer should maintain itself free from deposits, there will still be,
unavoidably, a certain amount of foul gas produced by the
decomposition of the matters coating its walls, and in order to dilute
and to remove this, and perhaps in order to modify their original
character, the most thorough ventilation is necessary.

Any sewer or other drain which at any time gives forth the odor of
putrid decomposition is in bad condition and should be at once
rendered inoffensive. So far as I know, there is no exception to this
rule. I have met no conditions in towns of any size where absolute
self-cleansing may {225} not be secured. It is worth while, however,
to repeat here the statement made above, that sewer gas, in so far as
it is a serious factor in connection with the drainage of houses, is
the product of the interior pipes of the house much more frequently
than of the public sewer in the street.

(_b_) The disposal of liquid wastes by irrigation, so far as this
method is applied to the outflow of public sewers, is not of especial
interest here, but an important modification has been made of the
system of irrigation which is of the greatest consequence in
considering the sanitary improvement of isolated country-houses, of
hospitals, prisons, etc., and of houses in towns about which there is
a small amount of available land. The process which has been found
best suited to the purpose is the invention of the Rev. Henry Moule,
the inventor of the earth-closet. He found it a serious drawback to
the dry-earth system that it was incapable of taking care of the
liquid wastes of the house. He devised a method of conducting the
liquid into very shallow drains made with open-jointed agricultural
drain-tiles, so porous in their character as to allow the liquid
carried by them to escape at the joints into the soil, and thus get
the benefit of its purifying qualities without the unsightly and often
offensive process of allowing the liquid to flow over the surface. The
first use made of this system was about 1866. Since that time its use
has extended very considerably both here and in England, and many
improvements have been made in its details, so that it may now be
accepted as entirely satisfactory.

The process in its best development, as applied to the drainage of
single houses, may be thus described, many of the appliances used
being the subject of patents: The outflow from the house is delivered
into a settling-basin or grease-trap of sufficient size to still the
flow, to cause solids to settle to the bottom, and grease and other
light matters to float at the top. The outlet from this basin is
through a pipe having its inlet at some distance below its
overflow-point; that is, at the level of the comparatively clarified
liquid, below the grease and above the sediment. The outflow passes
into another vessel known as a flush-tank, where it accumulates until
it reaches the summit of a self-acting siphon. This height being
reached, any considerable addition to the flow sets the siphon in
action, and the whole contents of the flush-tank are discharged with
rapidity into the drain beyond. The discharge completed, air is
automatically admitted to the siphon, and no further flow can take
place until the flush-tank has again been filled. The drain, of iron
or vitrified pipes tightly joined, is continued to the edge of the
ground prepared for purification. It here delivers into a series of
open-jointed agricultural tiles, laid with their bottoms not more than
ten inches below the surface of the ground. The total length of these
tile-drains is regulated according to the discharging capacity of the
flush-tank, with a view to their becoming entirely filled at each
discharge. Within a short time after the flow has ceased the liquid
has all left the pipes and entered the soil, its impurities being
retained and its filtered water settling away into the porous or
artificially drained ground below. During the interval between the
discharges of the flush-tank, a day or more, the process of
purification (oxidation) of the retained impurities goes on in the
soil, and its thorough aeration prepares it to purify the next
discharge. This method of {226} disposal is now employed in connection
with hundreds of houses, and its use, which has in some cases
continued for a dozen years, is constantly increasing. Its application
implies a certain amount of fall, but this amount need not be great.
The discharging height of the tank need not be more than twelve
inches. The main outlet need not fall more rapidly than at the rate of
1 to 300, and the absorption-drains ought not to fall more rapidly
than at the rate of 1 to 600. If the tank can be built on the top of
the ground, an average surface fall of 1 to 400 can usually be made to
meet all the requirements. Where waste matters are to be removed from
cellars and basements below the level of the ground, a greater fall is
necessary, or the wastes which are there collected must be thrown to
the tank by pumping or otherwise.

Where there is a bit of grass-land a little removed from the house
(and from sight), it answers a perfectly satisfactory purpose to
dispense with the absorption-drains and to deliver the main outlet
directly on to the surface of the ground. The effect in both cases is
entirely different from what it would be were the flow of the drains
not regulated by the use of the flush-tank. The moment we have a
constant slight discharge, either on the surface of the ground or into
the absorption-drains, we establish a condition of constant saturation
which leads to the over-fouling of a small area, which is rarely if
ever purified by aeration. For an intermittent discharge some form of
flush-tank is an absolute necessity. It is often found in practice,
where the flow from the house is considerable, that the discharge of
the house-drains into the settling-basin produces such an agitation of
its contents as to set in motion and to carry into the flush-tank bits
of paper partly macerated, grease, etc. This has been met by a recent
improvement, which consists in building a transverse wall in the
settling-basin, which checks the current from the house-drain and
causes the flow from the house side of the wall to pass over its top
in a thin small current which does not materially agitate the contents
of that part of the basin from which the outflow pipe is fed.

(_c_) The cesspool is still the chief reliance of the world at large.
There is nothing to be said in its favor save what may be based on the
old adage that "what is out of sight is out of mind." There is
everything to be said in its condemnation, whether we regard its
contents as a great mass of putrefying and infecting filth, as the
source of oozings which travel through crevices of rocks, through
layers of gravel, through seams in clay, or through lighter soils into
and under cellars and into drinking-water wells and defectively
constructed cisterns, or as an ever-active gas-retort supplying the
pipes of the house with the foulest products of putrefaction. It is in
all respects and under all circumstances a curse, unless placed far
away from the possibility of tainting the air we breathe or the soil
over which we live, or from which we or others take our
drinking-water, and even then it had better be abandoned.

The simple drainage of the soil involves a question of the greatest
importance. If the ground under the house or about it is at any time,
unless perhaps immediately after heavy rains, saturated with moisture,
we have to apprehend a condition of insalubrity more or less serious
in proportion to the degree of saturation and the degree of foulness
with which this is associated. The drainage requirements of land
outside of the house are less easily determined, but it requires
nothing more than a casual {227} examination of the cellar in
ordinarily wet weather to determine whether or not an improvement of
its soil-water drainage is necessary. If it is at such times wet, or
even persistently damp, thorough drainage is demanded; and it is only
necessary to say that this should be secured by some process which can
under no circumstances bring the air of the cellar into communication
with the air of a sewer or foul drain.

       *       *       *       *       *

I have purposely abstained in the foregoing remarks from invading the
province of the physician or the physiologist by discussing the
influence of bad drainage on the health of those living subject to it.
It may safely be assumed that physicians who care enough about the
subject to interest themselves in investigating the condition of local
or general drainage have convictions concerning it which could not be
strengthened by the opinion of one belonging to another profession.
The assumption is also confidently made that no intelligent medical
man will hesitate for a moment to accept the dictum that the site of
the house must be dry, and that it and its neighborhood must be
entirely exempt from the influence of foul organic decomposition.



{229}

GENERAL DISEASES.


FROM SPECIAL MORBID AGENTS OPERATING FROM WITHOUT.

  SIMPLE CONTINUED FEVER.

  TYPHOID FEVER.

  TYPHUS FEVER.

  RELAPSING FEVER.

  VARIOLA.

  VACCINIA.

  VARICELLA.

  SCARLET FEVER.

  RUBEOLA.

  ROTHELN.

  MALARIAL FEVERS.

  PAROTITIS.

  ERYSIPELAS.

  YELLOW FEVER.

  DIPHTHERIA.

  CHOLERA.

  PLAGUE.

  LEPROSY.

  EPIDEMIC CEREBRO-SPINAL MENINGITIS.

  PERTUSSIS.

  INFLUENZA.

  DENGUE.

  RABIES AND HYDROPHOBIA.

  GLANDERS AND FARCY.

  MALIGNANT PUSTULE.

  PYAEMIA AND SEPTICAEMIA.

  PUERPERAL FEVER.

  BERIBERI.



{231}

SIMPLE CONTINUED FEVER.

BY JAMES H. HUTCHINSON, M.D.


DEFINITION.--A continued, non-contagious fever, varying in duration
from one to twelve days, and in temperate climates almost invariably
ending in recovery. It may arise from any non-specific cause capable
of producing a temporary derangement of one or more of the important
functions of the body, is generally easily distinguished from the
other continued fevers by the absence of the characteristic symptoms
of these diseases, and presents in fatal cases no specific lesions.

SYNONYMS.--Synocha, vel Synochus Simplex, Febricula, Ephemera or
Ephemeral Fever, Irritative Fever, Ardent Continued Fever, Sun Fever.

HISTORY.--Much difference of opinion continues to prevail, even at the
present time, in regard to the existence of a simple continued fever,
which, on the one hand, occurs independently of local inflammations or
traumatic causes, and, on the other, is distinct from typhoid, typhus,
and relapsing fevers; many observers contending that the condition to
which this name is given is only a mild or modified form of one or
other of the graver varieties of continued fever, from which the
characteristic symptoms are absent. Prominently among modern writers,
Dr. Tweedie[1] has taken this view of the subject, for, after
reviewing the arguments for and against the recognition of simple
continued fever as a distinct disease, he asserts that there is not
sufficient evidence to justify us in encumbering our nosology with a
doubtful novelty. If, however, there is room for doubt as to its right
to a place in the list of diseases, there is certainly no good reason
for characterizing it as a novelty, since it has been referred to,
according to Murchison,[2] by many authors from the time of
Hippocrates down to the present day, who not only separate it from the
graver forms of fever, and give a very accurate description of its
symptoms, but seem to have been perfectly familiar with the causes
which give rise to it, and to have had very correct notions as to its
proper management. Thus, Riverius[3] was aware of the existence of two
forms of simple fever--the ephemeral, which lasts, as its name
implies, only a single day, and the Synochus Simplex, arising from the
same causes, but in which the fever continues for from four to seven
days. Strother[4] and Ball[5] also allude to this fever in terms that
leave no doubt upon the mind but that they distinguished it clearly
from other forms of continued fever. {232} Among more recent writers
who have made this distinction may be mentioned Lyons,[6] Jenner,[7]
G. B. Wood,[8] Flint,[9] Murchison,[10] and J. C. Wilson.[11] Indeed,
the weight of authority is decidedly on the side of those who claim
for it a recognition as a distinct and separate disease.

[Footnote 1: _Lectures on the Continued Fevers_.]

[Footnote 2: _A Treatise on the Continued Fevers of Great Britain_,
London, 1873.]

[Footnote 3: _The Practice of Physick, being chiefly a Translation of
the Works of Lazarus Riverius_, London, 1678.]

[Footnote 4: _A Critical Essay on Fever_, 1718.]

[Footnote 5: _A Treatise on Fevers_, London, 1758.]

[Footnote 6: _A Treatise on Fever_, London, 1861.]

[Footnote 7: _Medical Times_, March 22, 1851.]

[Footnote 8: _A Treatise on the Practice of Medicine_, Philadelphia,
1855.]

[Footnote 9: _A Treatise on the Principles and Practice of Medicine_,
Philadelphia, 1868.]

[Footnote 10: _Ibid._]

[Footnote 11: _A Treatise on the Continued Fevers_, New York, 1881.]

Unquestionably, many cases which have been classed under the head of
simple continued fever, are really mild or abortive cases of typhoid
or typhus fever, in which, in consequence of partial protection on the
part of the patient, the characteristic symptoms of these diseases
have not been developed. Such cases are seen in numbers during
epidemics of these diseases. But, making due allowance for this source
of error, there yet remain many cases which cannot be thus explained.
Moreover, the disease occurs at times when no such epidemics exist. It
may, therefore, be safely assumed that there is such a fever, and
that, consequently, it must be accorded full recognition.

CAUSES.--Any non-specific cause which is capable of producing a
profound derangement of one or more of the important functions of the
body may give rise to simple continued fever. It may follow,
therefore, upon excesses of the table, extreme mental or bodily
fatigue, exposure to the direct rays of the sun, or to great heat or
cold, or upon the suppression of a secretion. One of its most frequent
causes is over-exertion in warm weather. James C. Wilson has called
attention to its frequent occurrence as a consequence of the combined
influence of the excitement, the physical exhaustion, and the exposure
to the direct rays of the mid-day sun which are attendant upon
surf-bathing. It is often due in young children to the irritation
involved in the process of teething or to that caused by the presence
of worms in the alimentary canal. Wood taught that it might also
sometimes occur during the prevalence of contagious diseases as an
effect of the epidemic influence in those who were partially protected
by a previous attack of the disease, or from some other cause, but it
is more probable that cases arising under these circumstances are
either mild cases of the prevalent disease or else are attributable to
fatigue from nursing or to over-anxiety. The disease is more common in
the young than in the old, and in children than in adults--probably
from the greater impressionability of the nervous systems of the
latter.

The causes of the ardent continued fever of the tropics, which is
usually recognized as a form of simple continued fever, do not differ
materially, except in degree, from those of the simpler forms of the
disease; but exposure to the direct rays of the sun would seem to be
especially prone to give rise to the disease in those who are
unaccustomed to the heat of a tropical climate. Robust young Europeans
lately arrived in a warm country are, it is said, peculiarly liable to
suffer from it.[12] It is most common in those parts of India which do
not experience much of the benefit of the monsoon rains, and whose hot
season is not tempered by regular breezes from the sea. It is hence
more frequently met with {233} in inland districts in which the
temperature is high, but in which malaria-generating conditions are
absent.

[Footnote 12: Morehead, _Clinical Researches on Diseases in India_,
London, 1856; also Twining, _Clinical Illustrations of the More
Important Diseases of Bengal_, Calcutta, 1835.]

SYMPTOMS AND COURSE.--Simple continued fever occurs in this country
only as a sporadic disease, and almost invariably ends in recovery; in
tropical climates, however, it may prevail epidemically, and sometimes
presents symptoms of a very grave character. In its mildest form it
not infrequently runs its course in a few hours, and is rarely
prolonged much beyond twenty-four, and is hence called ephemera. It
then usually begins somewhat abruptly with a chill, but in a few
instances this is preceded by feelings of languor and weariness.
Febrile reaction is soon established, and is generally well marked;
the pulse is quick and full, the temperature rises rapidly, and the
face is flushed. The tongue is coated with a whitish fur, the urine is
scanty and high-colored, and the bowels are constipated. Other
symptoms are excessive thirst, headache, restlessness, and
sleeplessness, or, on the other hand, a tendency to somnolence.
Vomiting is not common except in those cases which follow upon an
error of diet, but there is generally some nausea and anorexia.
Muscular pains are also occasionally present, and may give rise to a
good deal of distress. The subsidence of these symptoms is often quite
as abrupt as their onset, the crisis being frequently marked by a
copious perspiration.

In other cases, however, the fever is more prolonged, and the
symptoms, although not differing in kind, are apt to be more severe
than those above detailed. The pulse is often full, hard, and
bounding; the headache throbbing or darting in character; the tendency
to somnolence increases, or gives place to delirium; and the pyrexia
is more marked. Frequently an eruption of herpes is observed upon the
lips and upon other parts of the face, from which circumstance the
disease is sometimes called herpetic fever. Davasse[13] also observed
in a few cases pale bluish spots, not elevated above the surface and
not disappearing under pressure, which are identical with the taches
bleuatres sometimes seen in typhoid fever and other diseases, and
therefore have no diagnostic value. In this form the duration of the
disease may be from four to ten or twelve days. The defervescence is
usually less rapid than the rise in temperature, and is generally
accompanied by a free perspiration, diarrhoea, a copious deposit of
urates in the urine, or less frequently by hemorrhage from the uterus
or rectum,[14] or from the nose, mouth, or urethra. This constitutes
the synocha or inflammatory fever of the older writers. In children in
whom there is no reason to suspect malarial poisoning the disease
sometimes assumes a remittent form, and then constitutes a variety of
the infantile remittent fever of authors--a name, however, which, it
must be remembered, has been made to include a great many distinct
diseases.[15]

[Footnote 13: Quoted by Murchison.]

[Footnote 14: Murchison.]

[Footnote 15: Lyons.]

When the disease occurs in individuals who are broken down in health
from any cause[16]--as, for instance, previous illness, deficient
food, long-continued anxiety, or great fatigue--it not infrequently
presents symptoms of an asthenic character. The febrile reaction is
then less intense, and the pulse feebler and more frequent, than in
the variety just described. The duration of the disease in this form
is also generally longer. Murchison has proposed for it the name of
simple asthenic fever.

[Footnote 16: Wood.]

Under the name of ardent continued fever, Indian medical writers have
described a variety of the disease which is frequently met with in
tropical {234} countries, and which is usually much more severe than
the varieties already referred to. In addition to the symptoms
presented by these, Morehead[17] says that there is often intolerance
of light and sound, contracted and subsequently dilated pupils,
ringing noises in the ears, anxious respiration, pains in the limbs
and loins, and a sense of oppression at the epigastrium. The bowels
are sometimes confined; at others vitiated bilious discharges take
place. The tongue is white, often with florid edges, and the urine
scanty and high-colored. At the end of from forty-eight to sixty hours
the febrile phenomena may subside, the skin become cold, and death
take place from exhaustion and sudden collapse. In some cases the
symptoms of cerebral disturbance are greater in degree, and in these
coma may soon supervene upon delirium. Convulsions, epileptiform in
character, with relaxation of the sphincters and suppression of urine,
also frequently occur, and occasionally cerebral hemorrhage. In other
cases the symptoms of gastritis are more prominent, or jaundice may
appear and aggravate the disease.

[Footnote 17: _Clinical Researches on Disease in India_, London, 1856.
See also "Croonian Lectures," by Sir Joseph Fayrer, _Brit. Med.
Jour._, April 29, 1882.]

Symptoms closely resembling those just described are occasionally met
with in this country in patients who have been exposed for some time
to the direct rays of the summer sun, but who have escaped a
sunstroke. Indeed, a few writers have been so much impressed with the
general resemblance which this latter condition bears to the fevers
that they have insisted upon including it in this group, and have
given it the name of thermic or heat fever. This view of the pathology
of sunstroke has, however, never been generally accepted.

One of the most characteristic symptoms of the disease in all its
forms is the rapid rise of temperature, which may in ephemera be as
great as from four to seven degrees in the course of a few hours, and
which may be followed in a few hours more by an equally abrupt
defervescence. When the fever is more prolonged, although the
temperature rises rapidly, it may not attain its greatest elevation
for from forty to sixty hours after the onset of the symptoms, and its
fall will be more gradual than in the preceding variety.
Unfortunately, there are no reliable thermometric records of ardent
continued fever. The urine is usually scanty and high-colored during
the height of the fever, especially in the severer forms of the
disease. Its specific gravity is high, and it contains a large amount
of solids, especially of urea. With the fall of the temperature it
rapidly increases in quantity, and is very apt to let fall a copious
lateritious sediment on cooling. According to Parkes,[18] who closely
observed six cases with the view of determining this question,
albuminuria does not occur at any stage of the disease. Convalescence
is usually rapid, and is not liable to be interrupted by the
occurrence of sequelae.

[Footnote 18: _The Composition of the Urine_, by Edmund A. Parkes,
M.D., London, 1860.]

DIAGNOSIS.--The diagnosis in those cases of simple continued fever in
which the connection between the disease and some one of the
conditions which have been referred to above as capable of exciting it
has been distinctly made out, presents little difficulty. It is
otherwise, however, when this relationship is not apparent. Indeed,
the symptoms of the disease so closely resemble those of an abortive
or mild attack of typhoid or typhus fever, in which the characteristic
eruption is wanting, that the {235} physician may sometimes remain in
doubt as to the nature of the disease he has been called upon to
treat, even after the recovery of the patient. This difficulty will of
course be especially likely to present itself during the epidemic
prevalence of these diseases. Simple continued fever may, however,
generally be distinguished from either of the latter by the much
greater severity of its initial symptoms, and particularly by the
rapid rise of temperature--a rise of from four to seven degrees in the
course of a few hours--which does not take place in these fevers, but
which, it must be remembered, may occur in erysipelas, measles,
pneumonia, and some other diseases. The absence of a characteristic
eruption, although it would not render it certain, would be in favor
of the diagnosis of simple continued fever, as would also the absence
of diarrhoea in cases in which there was difficulty in deciding
between this disease and typhoid fever. On the other hand, Murchison
regards the presence of an herpetic eruption on the lips as almost
pathognomonic of simple continued fever; but in this country such an
eruption is not an infrequent attendant upon fevers of malarial
origin, and many observers attach great importance to it in the
diagnosis of these diseases.

Simple continued fever is not likely to be mistaken for relapsing
fever, except during epidemics of the latter disease. It may be
discriminated from relapsing fever, the first paroxysm of which it
closely resembles, by the absence of severe articular pains, of
tenderness in the epigastric zone, of enlargement of the liver and
spleen, and of jaundice. It may be mistaken for tubercular meningitis,
especially in those cases in which the nervous symptoms are more than
usually prominent, or in which a hereditary predisposition to
tuberculosis exists; but its true nature may generally be recognized
by its more abrupt commencement, and by the absence of the constant
vomiting, screaming fits, strabismus, and paralysis so characteristic
of the latter disease.

It is scarcely necessary to add that a local inflammation or a
traumatic cause may give rise to symptoms simulating those of simple
continued fever, and that the diagnosis of this disease must be
uncertain until these conditions have been positively ascertained to
be absent, or, if present, until they have been proved to be
complications, and not the causes of the disease.

PROGNOSIS.--The prognosis of this disease, as it is met with in this
country, is favorable. Indeed, when uncomplicated it may be said to
end invariably in recovery, except in the aged and feeble, in whom,
when it occurs during the great heat of the summer season, it is apt
to assume the asthenic form, and to be accompanied by symptoms of a
grave character. The ardent continued fever of the tropics, on the
other hand, not infrequently terminates fatally, or may leave the
sufferer from it a chronic invalid for life, which is frequently
shortened by obscure cerebral or meningeal changes, which give rise to
irritability, impaired memory, epilepsy, headache, mania, partial or
complete paraplegia, or blindness.[19]

[Footnote 19: Sir Joseph Fayrer, K.C.S.I., M.D., F.R.S., _Brit. Med.
Jour._, April 29, 1881, p. 607.]

ANATOMICAL LESIONS.--Death so rarely occurs in this latitude from
simple continued fever that the opportunities for making post-mortem
examinations do not often occur. There are, however, a sufficient
number of such examinations on record to show that the disease gives
{236} rise to no specific lesions. According to Murchison and
Martin,[20] inspection in fatal cases of ardent continued fever
usually reveals the presence of great congestion of all the internal
organs and of the sinuses of the brain and pia mater, of an increased
amount of intracranial fluid, and occasionally of an effusion into the
abdominal cavity, and more rarely into the thoracic cavity.

[Footnote 20: _The Influence of Tropical Climates on European
Constitutions_, by James Ranald Martin, F.R.S., London, 1856.]

TREATMENT.--In the milder forms of the disease little or no treatment
is required--a fact which seems to have been recognized and acted upon
long ago, since Strother remarks that the cure of it is so easy that
physicians are seldom consulted about such patients. An emetic when
the attack has been caused by excesses of the table, and there is
reason to believe that there is undigested food in the stomach, a
purgative when constipation exists, and cooling drinks, the
effervescing draught or some other saline diaphoretic, are usually the
only remedies that are called for. In cases in which the febrile
action is more intense and prolonged, in addition to the use of these
remedies an effort should be made to reduce the heat of the skin and
the frequency of the pulse by sponging with cold water and by the
administration of digitalis and aconite. The headache which is often a
distressing symptom may usually be relieved by the application of
evaporating lotions, and restlessness quieted by the bromides.
Subsequently, quinia may be given with advantage. The patient should
be restricted to liquid diet during the continuance of fever.

In the asthenic form quinia and the mineral acids, nutritious food,
and very frequently alcoholic stimulants, must be given from the
beginning. In the treatment of the ardent continued fever of the
tropics the cold affusion or the cold bath, with quinia, would appear
to be indicated, but Morehead and other Indian physicians advise the
use of evacuants with copious and repeated venesections, cupping, and
leeches, aided by tartar emetic, till all local determination and the
chief urgent symptoms are removed; and Murchison expresses the belief,
founded on his own observations, that life is often sacrificed by
adopting less active measures.



{237}

TYPHOID FEVER.

BY JAMES H. HUTCHINSON, M.D.


DEFINITION.--An endemic infectious fever, usually lasting between
three and four weeks, and associated with constant lesions of the
solitary and agminate glands of the ileum, and with enlargement of the
spleen and mesenteric glands. Its invasion is usually gradual and
often insidious. Sometimes the only symptoms present in the beginning
are a feeling of lassitude, some gastric derangement, and a slight
elevation of temperature; at others there are slight rigors or chilly
sensations, headache, epistaxis, diarrhoea, and pain in the abdomen.
The principal symptoms of the fully-formed disease are a febrile
movement possessing certain characters, headache passing into delirium
and stupor, diarrhoea associated with ochrey-yellow stools,
tympanites, pain and gurgling in the right iliac fossa, a red and
furred tongue, which later often becomes dry, brown, and fissured; a
frequent pulse; an eruption of rose-colored spots, occurring about the
seventh or eighth day, slightly elevated above the surface,
disappearing under pressure, and coming out in successive crops, each
spot lasting about three days; prostration not marked in the
beginning, but rapidly increasing; and occasionally deafness, sweats,
and intestinal hemorrhages. When recovery takes place, the
convalescence is usually tedious, and may sometimes be protracted by
the occurrence of one or more relapses.

SYNONYMS.--The following are a few of the many names which have been
given to the disease at different times. Most of them have ceased to
be applied to it, and only three or four of them are at present in
general use: Febris Mesenterica, 1696; Slow Nervous Fever, 1735;
Febricula or Little Fever, 1740; Typhus Nervosus, 1760; Miliary Fever,
1760; Typhus Mitior, 1769; Synochus, 1769; Common Continued Fever,
1816; Gastro-Enterite, 1816; Entero-Mesenteric Fever, 1820; Abdominal
and Darm Typhus, 1820; Typhus Fever of New England, 1824;
Dothienterie, 1826; Enterite-folliculeuse, 1835; Infantile Remittent
Fever, 1836; Enterite Septicemique, 1841; Mucous Fever, 1844; Enteric
Fever, 1846; Intestinal Fever, 1856; Ileo-Typhus, 1857; Pythogenic
Fever, 1858; Mountain Fever, 1870.

NAME.--It has been objected to the name "typhoid fever" as a
designation for this disease that it tends to perpetuate among the
laity the mistaken impression that typhoid fever is only a modified
typhus fever, and also that the word typhoid has been generally
applied to a condition of system which is common to a great many
different diseases, {238} and which is not of necessity present in
this. In spite of these objections, and although it must be admitted
that they are not without force, I prefer to retain the name typhoid
fever, and for the following reasons: 1st. It was the name given to
the disease by Louis, to whom we owe the first full and accurate
description of it. 2d. It is the name by which it is best known to the
profession, not only in this country but abroad. 3d. No other name has
been proposed for it which is not quite as much open to criticism.
Thus the term enteric fever, originally suggested by the late George
B. Wood, and adopted by the London College of Physicians in its
_Nomenclature of Diseases_, is objectionable because it brings into
undue prominence the intestinal lesions and implies that they are the
cause of the fever. The same objection may be urged against the name
"intestinal fever," proposed by Budd. The name "pythogenic fever"
rests upon a theory of the disease which has never been proven, and is
regarded by most observers as untenable. Under these circumstances
even the influence of its distinguished proposer, the late Dr.
Murchison, has been insufficient to secure its adoption by the
profession at large.

HISTORY.--Certain passages in the writings of Hippocrates have been
appealed to by Murchison and other physicians in support of the
opinion that typhoid fever was a disease of at least occasional
occurrence in ancient times; but, although from the nature of its
causes it is probable that it has occurred in all ages and wherever
men have congregated in towns and villages, the descriptions given by
the Father of Medicine in the passages alluded to are not sufficiently
full to render it at all certain that typhoid fever had ever come
under his observation. Indeed, there is no author of an earlier date
than Spigelius[1] whose writings furnish any positive evidence that he
ever met with the disease. Spigelius, however, in spite of the doubt
thrown upon his observation by Hirsch,[2] would seem to have had
opportunities for examining the bodies of those who had died of it,
since he gives an account of several autopsies, in which he says that
the small intestine was inflamed and that that part of it next to the
caecum and colon was frequently sphacelated. Panarolus[3] also says
that the intestines had the appearance of being cauterized
("apparebant tanquam exusta") in some cases observed by him in Rome a
little later in the same century. Willis[4] would certainly appear to
have been familiar with two forms of fever, which, from the
description he gives of them, could have been nothing else but typhoid
and typhus fevers. Sydenham[5] also described a fever in which the
prominent symptoms were diarrhoea, vomiting, delirium, a tendency to
coma, and epistaxis, and which was distinguishable from the febris
pestilens by the absence of a petechial eruption. Baglivi[6] of Rome
in the latter part of the seventeenth century described the
haemitritaeus of previous writers {239} under the title of febris
mesenterica, and maintained that it was always accompanied by and
dependent on inflammation of the intestines and enlargement of the
mesenteric glands. A similar observation was made soon after by
Hoffmann,[7] and by Lancisi[8] in 1718. The latter seems to have fully
recognized the characteristics of the eruption, for he says that it
consisted of "elevated papules which disappeared completely on
pressure." In 1759, Huxham described, under the title "slow, nervous
fever," a disease which there can be no doubt was typhoid fever. He
moreover pointed out very clearly the distinctions between this
disease and another to which he gave the name of "putrid, malignant,
petechial fever," and which was unquestionably typhus. Sir Richard
Manningham[9] also described typhoid fever under the title of
"febricula, or little fever." In the preface of his work he calls
attention to its insidious origin, and to the fact that its gravity
was often underrated at its commencement, "till, at length, more
conspicuous and very terrible symptoms arise, and then the Physician
is sent for in the greatest hurry, and happy for the Patient if the
Symptoms, which are most obvious, do not, at this Time, mislead the
Physician to the Neglect of the little latent Fever, the true Cause of
these violent Symptoms." About the same time Morgagni[10] described
certain post-mortem examinations in which the lesions of the
intestines were evidently those of typhoid fever. Other authors, whose
works bear evidence that they were familiar with the symptoms or
lesions of typhoid fever, are Riedel, Roederer and Wagler, Stoll,
Rutty, Sarcone, Pepe, Fasano, Mayer, Wrenholt, Sutton, Bateman, Muir,
Edmonstone, Prost, Petit and Serres, Cruveilhier, Lerminier, and
Andral.

[Footnote 1: _De Febre Semitertiana_, Frankf., 1624; Op. Om.,
Amsterdam, 1745. Quoted by Murchison.]

[Footnote 2: _Handbuch der Historisch-Geographischen Pathologie_, von
Dr. August Hirsch, Stuttgart, 1881.]

[Footnote 3: _Observat. Med. Pentecostae; Romae_, 1652. Quoted by
Murchison.]

[Footnote 4: _Dr. Willis's Practice of Physick_, translated by Samuel
Pordage, London, 1684.]

[Footnote 5: _The Works of Thomas Sydenham, M.D., on Acute and Chronic
Diseases_, with a Variety of Annotations by George Wallis, M.D.,
London, 1788.]

[Footnote 6: _Opera Omnia Medico-practica et Anatomica_, Paris, 1788.]

[Footnote 7: _Opera Omnia Physico-Medico_, 1699. Quoted by Murchison.]

[Footnote 8: _Opera Omnia_, Geneva, 1718.]

[Footnote 9: _The Symptoms, Nature, etc. of the Febricula or Little
Fever_, London, 1746.]

[Footnote 10: Quoted by Hirsch.]

To Bretonneau[11] of Tours appears to belong the credit of having
first distinctly pointed out the association between certain symptoms
and the lesions of the solitary and agminated glands of the ileum. He
regarded the disease of the intestinal glands as inflammatory, and
therefore gave to it the name "dothienenterie" or "dothienenterite"
(from [Greek: dothien], a tumor, and [Greek: enteron], intestine),
but, unlike Prost, fully recognized the fact that there was no
necessary relation between the extent of the intestinal lesions and
the gravity of the febrile symptoms. Hirsch, however, claims this
honor for Pommer, whose little work on _Sporadic Typhus_ he thinks has
not received the consideration its merits deserve. Louis, to whom for
his careful study of typhoid fever we owe a large debt of gratitude,
was also fully aware of the lesions of the intestinal glands which
occur in this disease.

[Footnote 11: Quoted by Trousseau, _Archives Generales_, 1826.]

The progress in pathology which observers were making was temporarily
impeded about this time by the fact that while typhoid fever was of
frequent occurrence in Paris, typhus fever was comparatively rarely
met with and had not been epidemic there for several years.
Bretonneau, Louis,[12] Chomel, and indeed the greater number of
contemporary French physicians, therefore fell into the error of
supposing that the fever which was then common in England was
identical with that which they were describing, while the English
physicians of the period, with but few {240} exceptions, contended
with equal strenuousness that there was but one form of continued
fever, and that this was very seldom associated with disease of the
intestines. In the second edition of his work Louis abandoned his
former opinion, and admitted that the typhus fever of the English was
a very different disease from that which formed the subject of his
treatise; but the confusion which existed in England in regard to this
disease was not completely dispelled until the appearance in 1849 and
the following two years of several papers on this subject by Sir
William Jenner,[13] in which it was conclusively demonstrated that
typhoid and typhus fevers were separate and distinct diseases. In
Germany, however, the non-identity of these diseases was recognized as
early as 1810. Murchison says that the names by which they are still
generally known in that country, typhus exanthematicus and typhus
abdominalis, were given to them not long after.

[Footnote 12: _Researches Anatomiques, Pathologiques et Therapeutiques
sur la Maladie connue sur les Noms de gastro-entente, etc._, par P. C.
A. Louis, Paris, 1829.]

[Footnote 13: _Med. Chir. Trans._, vol. xxxiii.; _Edinburgh Monthly
Jour. of Med. Sci._, vols. ix. and x., 1849-50; and _Med. Times_,
vols. xx., xxi., xxii., xxxiii., 1849-51.]

The contributions made by American physicians to the knowledge of
typhoid fever have been both numerous and important. In 1824 it was
described by Nathan Smith[14] under the name of typhus fever of New
England, and in 1833, E. Hale, Jr.,[15] of Boston, published in the
_Medical Magazine_ for December an account of three dissections of
persons considered by him to have died of the disease. In reference to
these cases, Bartlett[16] says that if the diagnosis could be looked
upon as certain and positive they would constitute the first published
examples of intestinal lesion in New England. In February, 1835,
William S. Gerhard of Philadelphia, who was then under the impression
that the two diseases were identical, reported two cases under the
name of typhus fever, the symptoms and post-mortem appearances of
which he showed differed in no respect from those he had been
accustomed to see in the cases of typhoid fever he had observed with
Louis during his studies in Paris. The year after Gerhard had,
however, the opportunity of observing an epidemic of true typhus
fever, and was at once struck with the difference between the symptoms
of the cases which then fell under his care and of those he had seen
in Paris. In an admirable paper which appeared in the numbers of the
_American Journal of the Medical Sciences_ for February and August,
1837, he points out very clearly the differential diagnosis between
the two diseases. He particularly insisted on the marked difference
between the petechial eruption of typhus and the rose-colored eruption
of typhoid fever. He showed that the latter disease was invariably
associated with enlargement and ulceration of Peyer's patches and with
enlargement of the mesenteric glands, and that these conditions were
never presented in the former. He also fully recognized the fact that
typhus fever was eminently contagious, while, on the other hand, he
was fully aware that typhoid fever was not contagious under ordinary
circumstances, "although in some epidemics," he says, "we have strong
reason to believe it becomes so." The appearance of this paper marks
an epoch in the history of typhoid fever. Murchison, when speaking of
it, says that to Gerhard, and Pennock (who was associated with Gerhard
in his observations) certainly {241} belongs the credit of first
clearly establishing the most important points of distinction between
this disease and typhus fever, and M. Valleix alludes to it in terms
equally complimentary. It is undoubtedly owing to it, more than to any
other cause, that the differential diagnosis of these two diseases was
perfectly understood by the great body of the profession in this
country long before the question of the relation which they bore to
each other was definitely settled in Great Britain,[17] or even in
France.

[Footnote 14:  _Medical and Surgical Memoirs_, Baltimore, 1831.]

[Footnote 15: _Observations on the Typhoid Fever of New England_,
Boston, 1839.]

[Footnote 16: _The History, Diagnosis, and Treatment of the Fevers of
the United States_, 1842.]

[Footnote 17: The honor of having first clearly pointed out the
distinguishing characters of typhoid and typhus fevers has been
recently claimed for Sir William Jenner, but, as we have seen above,
his papers on this subject were not published until thirteen years
after that of Gerhard.]

Bartlett gave in the _Medical Magazine_, June, 1835, a short account
of the entero-mesenteric alterations in five cases of unequivocal
typhoid fever, which alterations, he said, corresponded exactly to
those described by Louis. In the same year, James Jackson, Jr., of
Boston, published an account of the intestinal lesions observed by him
in cases during the years 1830, 1833, and 1834; and again in a _Report
of Typhoid Fever_, communicated to the Massachusetts Medical Society
in June, 1838, says that the alterations of Peyer's patches had been
noticed at the Massachusetts General Hospital previous to 1833 in
cases which were carefully examined. In 1840, Shattuck of Boston
published in the _American Medical Examiner_ an account of some cases
of typhoid and typhus fever which he had observed at the London Fever
Hospital during the previous year. In this paper, which had been
already communicated to the Medical Society of Observation of Paris,
and which had unquestionably exerted a marked influence upon medical
thought there, he pointed out very fully the distinguishing
characteristics of each disease. In 1842, Dr. Bartlett issued the
first edition of his work on _The History, Diagnosis, and Treatment of
the Fevers of the United States_, which contains very full
descriptions of both of these diseases, and of the means by which they
may be distinguished from each other. Since then there have been
numerous additions in this country to the literature of typhoid fever,
among the most important of which may be mentioned the chapter on the
disease in the respective works on _The Practice of Medicine_ by
Professors Wood and Flint, the article on typho-malarial fever in the
_Transactions_ of the International Medical Congress of 1876, and the
article in the work on _The Continued Fevers_, by James C. Wilson.
Abroad, the medical press has been no less active. Within the last
twenty or thirty years Jaccoud and Trousseau in France, Liebermeister
and Hirsch in Germany, and Tweedie and Cayley in England, have all
made important additions to our knowledge of the disease. To the late
Dr. Murchison[18] of London, however, is justly due the honor of
having produced the best treatise on typhoid fever in any language,
and the writer cheerfully acknowledges that he has drawn largely upon
it for the material of the present article.

[Footnote 18: _A Treatise on Continued Fevers_, London, 1873.]

GEOGRAPHICAL DISTRIBUTION.--Although it will be generally admitted
that the conditions of civilization favor the occurrence and extension
of typhoid fever, yet there is abundant evidence that they are not
absolutely necessary to its production, as there is no country,
whether civilized or not, of the diseases of which we have any
knowledge, in which it has not occasionally made its appearance, being
met with in every variety of climate. It is endemic in North America,
attacking alike the inhabitants {242} of Greenland and British America
and those of Mexico. In our own country it prevails from time to time
in every State of the Union, committing its ravages as well among the
rocks and hills of New England as in the more fertile valleys of the
West and South. In many of the newly-settled portions of our country
malarial fevers are, as is well known, exceedingly rife. In
proportion, however, as towns and cities spring up, and as the land is
properly drained, they diminish in frequency, and are gradually
replaced, to a certain extent at least, by typhoid fever; but the
influences which produced them retain for a long time enough of power
to stamp their impress upon all other diseases. In large portions of
the Western and Southern States typhoid fever is therefore rarely
uncomplicated, and is much more likely to assume the form which will
be fully described later as typho-malarial fever.

Typhoid fever has also occurred frequently in Central America and the
West India Islands. It has prevailed from time to time in the states
of South America, and occasionally assumed in some of them--as, for
instance, Brazil and Chili--an epidemic form.

Typhoid fever is endemic in the British Isles, but, according to
Murchison, is most common in England, more common in Ireland than in
Scotland, and in Scotland more common on the west than on the east
coast. It also exists as an endemic disease in every country of the
continent of Europe, from Sweden and Norway on the north to Turkey on
the south, and in some of them--as, for instance, France and
Germany--would seem to be of much more frequent occurrence than in
this country, or even in England. Medical literature is also not
deficient in evidence that it has prevailed at various times in all
the different countries of Asia and Africa and in Australia. Morehead
asserted in the first edition of his _Clinical Researches on Diseases
in India_ that India enjoyed an absolute immunity from typhoid fever,
but in the second edition of this work he acknowledged that a larger
experience had led him to change his opinion on this point. Moreover,
the writings of Annesley, Twining, and other Indian authors furnish
convincing proof that the disease is by no means unknown in that
country. Indeed, even the relative immunity from it which it has been
claimed that tropical and subtropical countries possess has been
found, upon a fuller study of the diseases of these countries, not to
exist to anything like the degree that was formerly supposed.

The occasional occurrence of typhoid fever in islands separated from
the main land by a considerable distance--as, for instance, the island
of Norfolk,[19] which is situated in the Pacific Ocean four hundred
miles west of South America--is an interesting fact, and one which,
with the present limits to our knowledge on the subject, it is
impossible to explain satisfactorily.

[Footnote 19: Metcalfe, _Brit. Med. Jour._, Nov., 1880.]

The ETIOLOGY of typhoid fever may be considered under the heads of--1,
predisposing, 2, exciting causes.

1. PREDISPOSING CAUSES.--All observers agree that the predisposition
to typhoid fever is greater in childhood and early adult life than
after thirty years of age. Thus, Murchison states that during
twenty-three years nearly one-half the admissions to the London Fever
Hospital were of patients between fifteen and twenty-five years of
age, and that in more than a fourth, the patients were under fifteen
years. On the other hand, {243} in less than a seventh were they over
thirty, and in only one in seventy-one did their ages exceed fifty.
Taking these facts in connection with the circumstance that the entire
population of England and Wales in 1861 was 12,481,323 persons under
thirty years of age and 7,584,901 above thirty, it follows, he says,
that persons under thirty are more than four times as liable to
enteric fever as persons over thirty. Jackson found that the average
age of the patients in two hundred and ninety-one cases observed at
the Massachusetts General Hospital was a little over twenty-two years,
the average age in the fatal cases being somewhat greater than in
those in which recovery took place. Liebermeister, from an analysis of
a large number of cases treated at the hospital in Basle, has arrived
at the same conclusion. No age, however, enjoys a complete immunity
from the disease. Manzini[20] has recorded a case in which lesions of
Peyer's patches similar to those of typhoid fever were found in a
seventh-month foetus which died within half an hour after its birth.
Cases are also on record in which death has occurred from this disease
in the first few weeks of life. I have myself observed several cases
in young children at the Children's Hospital in Philadelphia. The
probability is, that it is of even more frequent occurrence in
children than is generally supposed, as this class of patients is not
often admitted into general hospitals, and as from the absence of some
of its characteristic symptoms when it occurs in the very young the
nature of the disease is often unrecognized.

[Footnote 20: Quoted by Murchison.]

On the other hand, the disease occurs not infrequently in advanced
life: 83 cases out of 5911 were observed at the London Fever Hospital
in persons over fifty, 27 in persons over sixty, and in 2 the age was
seventy-five. In a case recorded by D'Arcy the age of the patient was
eighty-six, and in one reported by Hamernyk it was ninety.[21]
Bartlett long ago contended that the disease was not so rare as was
generally supposed among people over forty years of age; and there is
really no good reason to believe that the susceptibility to the causes
of the disease in an unprotected person diminishes with advancing
years, the immunity from this disease which elderly people appear to
enjoy being probably due to the fact that, as the disease is not
uncommon in early life, they are in many instances protected by having
already passed through an attack.

[Footnote 21: Quoted by Murchison.]

The mean age of the male patients treated at the London Fever Hospital
was slightly in excess of that of the female, but in the cases
analyzed by Jackson the reverse of this was observed.

The statistics of all general hospitals, with very few exceptions,
show a greater or less preponderance of males over females among the
typhoid fever patients treated in them. According to Murchison, of
5988 cases admitted into the London Fever Hospital during twenty-three
years, 3001 were males and 2987 were females. Of 891 cases admitted
into the Glasgow Infirmary during twelve years, 527 were males and 364
females. Liebermeister states that 1297 male typhoid patients and 751
female were treated in the hospital at Basle from 1865 to 1870.
Occasionally, the difference is even greater than is indicated by
these figures. Thus, of 138 cases observed by Louis, all but 32
occurred in males. When, however, we consider that the proportion of
men who apply for admission to hospitals when sick is much larger than
that of women, we should hesitate before accepting these statistics as
proof that the former {244} are more liable to be attacked by typhoid
fever than the latter. Indeed, the opinion which Murchison expresses
is generally accepted as correct by authors, that neither sex is more
likely than the other to contract the disease. Liebermeister asserts
that pregnant and puerperal women and those who are nursing infants
enjoy a relative immunity. On the other hand, Nathan Smith says that
while the sexes are equally liable to it, more women are cut off by it
than men, in consequence of its appearance during pregnancy or soon
after parturition.

It was long ago pointed out by certain French observers that newcomers
are much more liable to be attacked by typhoid fever than persons who
have lived for some time in an infected locality. In 129 cases
examined with reference to this point by Louis, the patients in 73 had
not resided in Paris more than ten months, and in 102 not more than
twenty months. Bartlett noticed that during an epidemic in Lowell
which he had the opportunity of observing the disease attacked the
recent residents in much larger proportion than the old. Liebermeister
also calls attention to this peculiarity of the disease. Murchison's
experience in reference to this point has been somewhat similar, for
he found upon examination of the records of the London Fever Hospital
that 21.84 per cent. of the patients admitted there for typhoid fever
had been residents of London for less than two years. Almost all of
these patients came, he says, from the provinces of England, and were
in good health and comfortable circumstances at the date of their
arrival in London and for some time after. Moreover, a large
proportion of them were first attacked within a few weeks after
changing their residence from one part of London to another. He also
refers to instances in which successive visitors at the same house at
intervals of months, or even years, have been seized shortly after
their arrival with typhoid fever or with diarrhoea, from which the
ordinary occupants were exempt. These facts indicate with sufficient
clearness that habitual exposure to the causes of the disease confers,
to a certain extent at least, an immunity from their effects, just as
it does in the various forms of disease arising from malaria. It is
not unlikely, as has been suggested by Wilson,[22] that one of the
causes of the frequency of typhoid fever in the early autumn in our
American cities among well-to-do people is to be formed in the
circumstance that during an absence of two months or more in the
mountains or by the sea they have to some extent lost the immunity
acquired by habitual exposure to sewer emanations, and return to the
atmosphere of the city unprotected.

[Footnote 22: The occurrence of typhoid fever in the early fall among
persons who have spent the summer out of town is, however, susceptible
of another explanation. In many instances they have returned to houses
which have been not only unoccupied, but closed, during several
months, and which, in consequence of the more or less complete
evaporation of the water in the traps of the drain-pipes, have been
thoroughly permeated by sewer gas.]

There is no evidence that any particular occupation acts as a
predisposing cause of typhoid fever. Among the 621 patients treated at
the Pennsylvania Hospital during the last ten years, were
representatives of every branch of industry, and the same fact has
been observed at every general hospital, not only in this country, but
abroad. There is also no reason to believe that the station in life of
itself exerts much influence in predisposing to the disease. The rich
suffer equally with the poor. It would appear, indeed, that since the
recent general introduction of ill-ventilated water-closets and
stationary washstands into the houses of the {245} better classes the
liability of the former to suffer from the disease is greater than
that of the latter.

Persons recovering from an illness or in an infirm condition of health
do not appear to be more liable than others to be attacked by typhoid
fever. Among the many patients who have fallen under my care only a
very few were in ill-health at the time of their seizure. The same
fact has been noticed by Murchison and other observers. Indeed,
Liebermeister goes so far as to say that typhoid fever attacks by
preference strong and healthy persons, while it avoids those suffering
with chronic ailments. That this latter class of patients enjoys no
immunity from the disease when exposed to its causes is shown by a
fact which he himself records. During his service at the hospital at
Basle from 1865 to 1871 several of the patients in the medical and
surgical wards were attacked by typhoid fever, the cases being
especially numerous in two rooms which were situated one directly over
the other. Upon investigation it was found that a wooden pipe which
extended from the sewer to the roof ran by both of these rooms. The
sewer at the point where this pipe ran into it was of faulty
construction, and was turned at a right angle, so that the refuse
matter collected there. Since this source of infection was made known
repeated cleansings, washings, and disinfections have been followed by
satisfactory improvement, and Liebermeister believes that if the sewer
were entirely altered the infection would disappear.

It would seem only natural that intemperance, by diminishing the
powers of resistance in the individual, would increase his liability
to contract typhoid fever, but there is no proof that it does so. Few
of the patients who have come under my care were intemperate, and
still fewer were broken down by this cause. There is also no evidence
that grief, fear, or any other depressing emotion is a predisposing
cause of the disease, and the same may be said of bodily fatigue and
overcrowding. On the other hand, much importance has been attached by
writers to idiosyncrasy as a predisposing cause of typhoid fever. What
the peculiarities of constitution are which increase the liability to
the disease are not definitely known, but there can be no question
that it occurs much more frequently, and is much more fatal, in some
families than in others.

Typhoid fever occurs with the greatest frequency in this country, as
it does with very few exceptions elsewhere, during the latter half of
summer and the early part of autumn. Indeed, its greater prevalence at
this season than at other times has given to it the name of "autumnal"
and "fall fever," by which it is popularly known in many sections of
this country as well as of England. On the other hand, the disease is
usually at its minimum in May and June. The number of cases, however,
does not usually immediately diminish upon the onset of cold weather.
On the contrary, R. D. Cleemann,[23] from a comparison of the
mortality returns of Philadelphia for a period of ten years, observed
that after diminishing in November they not infrequently underwent a
marked increase in December. Of 621 cases treated at the Pennsylvania
Hospital during the last ten years, 89 were admitted during spring,
259 during summer, 182 during autumn, and 91 during winter. Of 5988
cases treated at the London Fever Hospital,[24] 759 were admitted in
the {246} spring, 1490 in summer, 2461 in autumn, and 1278 in winter.
Of the whole number, 27.7 per cent. were admitted in the two months of
October and November, and in April and May only 7.3 per cent.
Hirsch[25] has published statistics which do not differ materially
from these. He also mentions the interesting fact that in Rio Janeiro
the maximum of the disease occurs in the months from March to June,
or, in other words, in the season which in that latitude corresponds
to our autumn. There are, however, some exceptions to the general rule
of the greater prevalence of the disease during the autumn. Bartlett,
who was aware of its greater frequency at that time, refers to an
extensive and fatal epidemic which occurred in the city of Lowell in
Massachusetts during the winter and early spring; and similar
visitations have been observed in other places.

[Footnote 23: _Transactions of the College of Physicians of
Philadelphia_, 3d S. vol. iii.]

[Footnote 24: Murchison.]

[Footnote 25: _Handbuch der Historisch-Geographischen Pathologie_,
Stuttgart, 1881.]

Most authors agree with the statement made by Murchison, that typhoid
fever is unusually prevalent after summers remarkable for their
dryness and high temperature, and that it is unusually rare in summers
and autumns which are wet and cold. Certainly, the severest epidemic
of the disease which has been observed in Philadelphia in several
years occurred in the year 1876, during and after a summer of
exceptionally high temperature, and one characterized by a decidedly
diminished rainfall. Still, there can be no question that the
increased prevalence of the disease at this time was due, in part at
least, to the crowded condition of the city consequent upon the
Centennial Exhibition. In 1872, although the mean of the summer
temperature was slightly higher than that of 1876, the disease did not
prevail in an epidemic form. This may be explained by the fact that
the rainfall of the summer months of this year was decidedly greater
than the average. Hirsch, however, attaches much less importance to
temperature as a factor in the production of typhoid fever than most
other authors. He says that he has found, from a comparison of a large
number of epidemics, that the disease occurs almost as often in cool
as in hot summers, in cold as in warm autumns, and in mild as in
severe winters. Murchison, moreover, admits that mere dryness of the
atmosphere is not conducive to an increase of typhoid fever. On the
contrary, he says, warm, damp weather, when drains are most offensive,
is often followed by an outbreak of the disease.

The relation which temperature and moisture bear to the causation of
typhoid fever is therefore not definitely ascertained. It is certain,
however, that the largest number of cases does not occur at the period
of the greatest heat, but is usually not observed until from six weeks
to two months afterward, and the minimum is not reached until about
the same length of time after that of the most intense cold. This
difference in time Murchison explains by the hypothesis that the cause
of the disease is exaggerated or only called into action by the
protracted heat of summer and autumn, and that it requires the
protracted cold of winter and spring to impair its activity or to
destroy it. On the other hand, Liebermeister, who believes that the
breeding-places of typhoid fever lie deep in the earth, holds that the
time is consumed in the penetration of the changes of temperature to
the place where the typhoid poison is elaborated, in the development
of the poison without the human body, and in the period of incubation.
In some places the maximum of the disease is observed earlier in the
year than in others. In Berlin, for {247} instance, the largest number
of fatal cases occurs in October, while in Munich it does not occur
until February. This depends, he thinks, upon the difference in the
distance beneath the earth's surface of these breeding-places in
different localities, and the deeper they are the longer, he says,
will it be before they are affected by the heat of summer or the cold
of winter, since the changes of the temperature of the air are
followed by corresponding changes in the temperature of the earth more
and more slowly the deeper we go beneath the surface.

Buhl and Pettenkofer have, as the result of a series of observations
carried on in Munich over a number of years, reached the conclusion
that an intimate relation exists between the variations in the degree
of prevalence of typhoid fever and the rise and fall of water in the
soil. When the springs were low they found that there was a marked
increase in the number of cases; when, on the other hand, they were
high, there was just as decided a diminution. Out of this fact they
have evolved the theory that the cause of typhoid fever lies deep in
the soil, and has the power of multiplying itself there, and that this
property is very much increased when the water-level sinks, and the
upper layers of the earth are consequently exposed to the air. It is,
on the contrary, diminished when the water-level rises and the earth
is again saturated with moisture. It is unquestionably true, as has
already been stated, that it is principally after hot and dry weather,
when the springs are of course low, that typhoid fever is most
prevalent, and that it very frequently subsides after the occurrence
of very heavy rains; but it is not necessary to adopt the theory of
Buhl and Pettenkofer to explain these facts. It seems quite as
probable that the increased prevalence of the disease after dry
weather is due, as suggested by Buchanan and Liebermeister, to the
greater amount of solid matter which is then suspended in the water of
the springs. A larger proportion of the germs of the disease, if there
should be any present in the soil, will therefore be contained in any
given quantity of the drinking-water. The theory fails to account, as
pointed out by Murchison, for the connection which is frequently
observed between defective house-drainage and outbreaks of typhoid
fever, occurring irrespectively of any variations in the subsoil
water. And, moreover, outbreaks of the disease have occurred under
precisely opposite circumstances, as the outbreak at Terling in 1867,
recorded by Thorne,[26] which was coincident with a rise in the
subsoil water after drought.

[Footnote 26: Quoted by Murchison.]

It is believed in many parts of our country that there is an
antagonism between typhoid fever and the various forms of malarial
fever, and it is unquestionably true that in many districts in which
the latter were formerly prevalent they have ceased to be frequent,
and have been replaced apparently by the former. In the cultivation of
the soil the causes of malarial fever disappear, or at least become
less potent. On the other hand, the increase of population and the
neglect of all sanitary laws in the building of towns, and the
construction of sewers with their house connections, seem to favor the
occurrence of typhoid fever. But there is no real antagonism between
the diseases. During the recent Civil War typhoid fever was not
infrequently developed in soldiers suffering from malarial disease.
Indeed, so frequent was it to have the manifestations of the two
diseases in the same individual that many observers at that {248} time
supposed they had a new disease to deal with, to which they gave the
name of typho-malarial fever.

2. EXCITING CAUSES.--Much diversity of opinion has existed in times
past and to a certain extent continues to exist, in regard to the
contagiousness of typhoid fever. In the early part of this century
there was quite a number of good observers, including Nathan Smith in
this country, and Bretonneau and Gendron of Chateau du Loir in France,
who held the opinion it was an eminently contagious disease. Indeed,
Smith went so far as to say that its contagiousness was as fully
demonstrated as that of measles, small-pox, or any other disease
universally admitted to be contagious. This was also the opinion of
William Budd, who maintained that the contagious nature of typhoid
fever was the master truth in its history. The late Sir Thomas Watson
was also a warm supporter of the same view. At the present time,
however, the large majority of physicians, whose opportunities for
observation give weight to their opinions, do not regard the disease
as contagious in the strict sense of the word. During the past
twenty-four years I have been almost uninterruptedly connected with
large general hospitals, and during that time have had a large number
of cases of typhoid fever under my care, and a still larger number
more or less under my observation. During all this time I have never
known but one case to originate within a hospital, and that occurred
in a servant whose duties did not bring her in immediate contact with
the sick. Murchison's experience with a much larger number of cases
has been very similar. In twenty-three years, in which 5988 cases were
treated in the London Fever Hospital, only 17 residents contracted the
disease, and most of these had no personal contact with the sick.
Liebermeister asserts that he has never known a case to originate in a
hospital from direct contagion. When such cases appeared to have
occurred, they could generally be traced, he says, to some defective
sanitary condition of the hospital.

There are, nevertheless, many facts on record which, unless duly
weighed, appear to lend a good deal of support to the theory of the
contagiousness of typhoid fever. Among the most important of these are
(1) the occurrence in rapid succession of several cases in the same
house, and (2) the limited epidemics which occasionally follow the
arrival of an infected person into a previously healthy locality.
These facts are, however, susceptible of an entirely different
explanation.

1. In those instances in which several cases of the disease have
occurred in the same house, it not infrequently happens that some
defect in its sanitary conditions is detected, or that the
drinking-water is found to be impure. The same cause which produced
the first case may, therefore, also have produced those which
succeeded it. Indeed, the interval between the cases is sometimes so
short that for this reason alone, if there were no other, they could
scarcely be attributed to contagion. It not infrequently happens that
the seizure of one member of a large family is followed on the next
day by that of another, and on the third or fourth by that of still
another. Now, while it is undoubtedly true that the period of
incubation has appeared in some cases to be very short, we know that
under ordinary circumstances it is usually about two weeks.

2. The explanation of the second fact is not more difficult, but in
order that it may be clear to the reader it will be well to give in
detail a few {249} of the instances on record in which the arrival of
an individual sick with typhoid fever in a previously healthy locality
has been followed by an outbreak of the disease. Nathan Smith refers
to two cases of this character. In both of these the disease appeared
to be communicated to several individuals by patients who had
contracted the disease elsewhere. So little is said in the reports of
these cases of the water-supply of the localities in which they
occurred, or of the manner of disposing of the discharges of the
patients, that they would scarcely now be used as arguments in favor
of the contagiousness of the disease. The report of a local epidemic
by Austin Flint, Sr., is more satisfactory in this respect, and is as
follows: A stranger was detained in a small village near Buffalo by an
illness which proved fatal in the course of a few days, and which was
recognized as typhoid fever by his attending physicians. Up to this
time, it is stated, typhoid fever had never been known in the
neighborhood. In the course of a month more than one-half of the
population, numbering forty-three, was attacked by the disease, and
ten had died. The family of the tavern-keeper at whose house the
stranger lodged was the first to suffer, and of the families
immediately surrounding the tavern but one wholly escaped, that of a
man named Stearns. Upon investigation, it was ascertained that this
family alone, of all these families, did not use the well belonging to
the tavern, but had its own water-supply. The occurrence of the
disease naturally produced great excitement, and Stearns, between whom
and the tavern-keeper a quarrel existed, was suspected of having
poisoned the well; but an examination of the water showed this
suspicion to be unfounded. There can, however, be little doubt that
the water of the well, which was in all probability contaminated by
the discharges of the stranger, was the means of propagating the
disease; for although it is said that the family of Stearns was cut
off by the quarrel from all intercourse with that of the
tavern-keeper--a fact upon which some stress is laid by Flint--it does
not appear that a similar isolation existed as regards the other
families affected.[27]

[Footnote 27: _A Treatise on the Principles and Practice of Medicine_,
by Austin Flint, M.D., Philadelphia, 1868.]

The manner in which the arrival of a sick person may cause the
dissemination of the disease in a previously healthy community is even
better shown by the following histories of local outbreaks:[28]

"The water-supply pipes of the town of Over Darwen were leaky, and the
soil through which they passed was soaked at one spot by the sewage of
a particular house. No harm resulted till a young lady suffering from
typhoid fever was brought to this house from a distant place. Within
three weeks of her arrival the disease broke out and 1500 persons were
attacked. At Nunney a number of houses received their water-supply
from a foul brook contaminated by the leakage of a cesspool of one of
the houses, but no fever showed itself till a man ill with typhoid
came from a distance to this house. In about fourteen days an outbreak
of fever took place in all the houses."

[Footnote 28: Wm. Cayley, M.D., _Brit. Med. Jour._, March 15, 1880.]

There are many other observations which seem to render it certain that
the alvine dejections are a most important medium by which typhoid
fever is communicated to others; and yet there is no evidence that
they possess this power in a fresh condition. They have been
repeatedly examined, and even handled, with impunity, and, as has
already been stated, it {250} is rare for the disease to be imparted
to the immediate attendants upon the sick, or in a well-ventilated
hospital to the other patients in the same ward, provided that the
discharges are disinfected and removed immediately after being passed,
and the bed-linen and clothes of the patient changed whenever they are
soiled. The feces must therefore undergo some changes before they
become possessed of virulent properties. This appears to be shown
conclusively by the following facts: (1) laundresses who wash the
soiled clothes of typhoid fever patients not infrequently contract the
disease; (2) the occupants of houses connected by ill-trapped drains
with sewers into which the discharges of such patients have found
their way often suffer severely from the disease; and (3) the use of
water polluted by such discharges is, as has already been shown,
almost certain to induce the disease in persons not protected by a
previous attack.

The following histories of outbreaks of typhoid fever will show
clearly how the dejections of patients may be the means of propagating
the disease to others:

ILLUSTRATIVE CASES--Lausen[29] is a village lying on the railway
between Basle and Olten shortly before coming to the great Hauenstein
Tunnel. It is situated in the Jura, in the valley of the Ergolz, and
consists of 103 houses with 819 inhabitants. It was remarkably
healthy, and resorted to on that account as a place of summer
residence. With the exception of six houses it is supplied with water
by a spring with two heads which rises above the village at the
southern foot of a mountain called the Stockhalder, composed of
oolite. The water is received into a well built covered reservoir, and
is distributed by wooden pipes to four public fountains, whence it was
drawn by the inhabitants. Six houses had an independent supply--five
from wells, one from the mill-dam of a paper-factory. On August 7,
1872, ten inhabitants of Lausen, living in different houses, were
seized by typhoid fever, and during the next nine days fifty-seven
cases occurred, the only houses escaping being those six which were
not supplied by the public fountains. The disease continued to spread,
and in all 130 persons were attacked, and several children who had
been sent to Lausen for the benefit of the fresh air fell ill after
their return home. A careful investigation was made into the causes of
this epidemic, and a complete explanation was given. Separated from
the valley of the Ergolz, in which Lausen lies, by the Stockhalder,
the mountain at the foot of which the spring supplying Lausen rises,
is a side valley called the Furjust, traversed by a stream, the
Furlenbach, which joins the Ergolz just below Lausen, the Stockhalder
occupying the fork of the valley. The Furlenthal contains six
farm-houses, which were supplied with drinking-water, not from the
Furlenbach, but by a spring rising on the opposite side of the valley
to the Stockhalder. Now, there was reason to believe that under
certain circumstances water from the Furlenbach found its way under
the Stockhalder into one of the heads of the fountain supplying
Lausen. It was noticed that when the meadows on one side of the
Furlenbach were irrigated, which was done periodically, the flow of
water into the Lausen spring was increased, rendering it probable that
the irrigation water percolated through the superficial strata and
found its way under the Stockhalder by subterranean channels in the
limestone rock. Moreover, some years before a {251} hole on one
occasion formed close to the Furlenbach by the sinking in of the
superficial strata, and the stream became diverted into it and
disappeared, while shortly afterward the spring of Lausen began to
flow much more abundantly. The hole was filled up, and the Furlenbach
resumed its usual course. The Furlenbach was unquestionably
contaminated by the privies of the adjacent farm-houses; the soil-pits
communicated with it. Thus, from time immemorial, whenever the meadows
of the Furlenthal were irrigated the contaminated water of the
Furlenbach, after percolation through the superficial strata and a
long underground course, helped to feed one of the two heads of the
fountain supplying Lausen. The natural filtration, however, which it
underwent rendered it perfectly bright and clear, and chemical
examination showed it to be remarkably free from organic impurities,
and Lausen was extremely healthy and free from fever. On June 10th one
of the peasants of the Furlenthal fell ill with typhoid fever, the
source of which was not clearly made out, and passed through a severe
attack with relapses, so that he remained ill all summer; and on July
10th a girl in the same house, and in August a boy, were attacked.
Their dejections were certainly, in part, thrown into the Furlenbach;
and, moreover, the soil-pit of the privy communicated with the brook.
In the middle of July the meadows of the Furlenthal were irrigated as
usual for the hay crop, and within three weeks this was followed by
the outbreak at Lausen.

[Footnote 29: William Cayley, M.D., _British Medical Journal_, Mar.
15, 1880.]

In order to demonstrate the connection between the water-supply of
Lausen and the Furlenbach, the following experiments were performed.
The hole mentioned above as having on one occasion diverted the
Furlenbach into the presumed subterranean channels under the
Stockhalder was cleared out, and 18 cwt. of salt were dissolved in
water and poured in, and the stream again diverted into it. The next
day salt was found in the spring at Lausen. Fifty pounds of wheat
flour were then poured into the hole, and the Furlenbach again
diverted into it, but the spring at Lausen remained clear, and no
reaction of starch could be obtained, showing that the water must have
found its way under the Stockhalder, in part by percolation through
the porous strata, and not by distinct channels.

Volz[30] refers to an epidemic which occurred at Gerlachsheim, a
village of Germany, some years ago, in which, in the course of three
weeks, 52 persons residing on one of the principal streets were
attacked by the disease. It was found, upon investigation, that they
all got their water from a well which was polluted by the stools of
the first patient. A. Pasteur[31] reports an epidemic caused by the
contamination of a well by typhoid dejections, and which ceased when
the use of the water was discontinued. Niericker[32] also reports an
outbreak which was found to be due to a similar pollution of the
drinking-water, and which likewise ceased when the water-supply was
derived from another source.

[Footnote 30: _Schmidt's Jahrbuch_.]

[Footnote 31: _Revue med. de la Suisse_, Mars 15, 1881.]

[Footnote 32: _Schweiz. Corr. Bl._, ix. 1, 1879.]

An outbreak of the disease which occurred in a farm-house situated
about eight miles from the city of Philadelphia came under my own
observation. The first case occurred in a young girl of sixteen, who,
with the exception of an occasional visit to the city, had not been
away from her own home for several months before she was {252} taken
ill. The disease ran in her a severe course, and eventually terminated
fatally. About three weeks afterward four other members of the family
were attacked, one of whom died. Two other persons, living in a house
on the opposite side of the road, but who were in the habit of
drinking water from the same well, also took the disease. There was no
other case of typhoid fever in the immediate vicinity, nor had there
been for some time. The farm-house is situated in a cup-shaped
depression, so that water flowed toward it from all directions. The
cellar was constantly filled with water during the winter, and just
before the outbreak had contained not only an unusually large
quantity, but also a large amount of decaying vegetable matter. The
well from which the family drew their drinking-water is situated
within a few feet of the kitchen door, and at some distance from the
cesspool used by the family, so that there was no reason to believe
that there was any communication between the two. The wall of the well
was found to be very much loosened by the roots of two trees growing
in the immediate vicinity. As the ground was also very much cut up by
the burrows of rats, the water used for the various household
purposes, and which was habitually thrown into a gutter which ran past
the well, found a ready access to it. There would seem to be but
little doubt that the first patient contracted the disease in some way
during her visits to the city, and that the disease in the other
patients arose from their drinking the water of the well which had
been polluted by that used in washing her soiled linen.

Ballard[33] has shown very clearly that milk may also be a medium of
communication of the disease. He found that an epidemic which occurred
in the parish of Islington, London, in 1871 was (1) almost entirely
confined to a district comprised within a circle having a radius of
not more than a quarter of a mile; (2) that out of 62 families living
within this district, who were known to have suffered from typhoid
fever, 54 were constantly supplied with milk from a particular dairy,
and it was satisfactorily proved that at least three of the remaining
eight had occasionally partaken from the same source; and (3) that out
of 142 families, comprising all the customers of this dairy, and
living not only within the district above specified, but in other
parts of the parish, 70, or very nearly one-half, were invaded by
typhoid fever within the ten weeks during which the outbreak lasted.
Upon a visit to the farm from which the milk came it was ascertained
that a member of the dairyman's family had been ill with typhoid
fever, and that the water of the well which supplied the family with
drinking-water had been polluted by his discharges. Although the
dairyman denied that this water had ever been mixed with the milk, he
admitted that it had been used to wash the milk-pans. Murchison was
also able, in an outbreak which occurred in another district of
London, to trace the disease to the same source.

[Footnote 33: _On a Localized Outbreak of Typhoid Fever in Islington_,
London, 1871.]

Typhoid fever may be likewise propagated in consequence of the
contamination of the atmosphere by the typhoid poison. This may be the
result of allowing the undisinfected stools, or linen soiled by them,
to remain for some time exposed to the air, or may arise from
pollution {253} of the soil from the same cause or from defective
sewage. Hermann Schmidt[34] refers to several epidemics breaking out
in garrisons which he believed to be due to pollution of the soil. In
the citadel of Wurzburg typhoid fever occurred through several years,
and persisted in spite of the cutting off of the water-supply, which
was believed to be impure. It was finally found that the ground upon
which it was built was saturated with all kinds of impurities. Volz
refers to outbreaks of the disease from the same cause.

[Footnote 34: _Die Typhus Epidemie in Fusillier Bat. zu Tubingen in
Winter 1876-77, enstanden durch einathmung, giftiger Grundluft_,
Tubingen, 1880.]

But perhaps the most striking example of this mode of propagation of
the disease is that recorded by Budd,[35] and is as follows: Two
adjacent cottages, which for the sake of convenience may be designated
as Nos. 1 and 2, had a privy in common, which was in the form of a
lean-to against the gable end of No. 2. Through this privy there
flowed with very feeble current a small stream which formed the
natural drain for it. Having already performed this office for some
twenty or thirty other houses higher up its course, the stream had
acquired all the character of a common sewer before reaching the
cottages in question. About a quarter of a mile farther on it acted as
a drain for a privy, common as before, for two other cottages, Nos. 3
and 4. Notwithstanding the condition of the stream, which was so foul
that it was said that the stink from it was often enough "to knock a
man down," no evil result appeared to have occurred until a man living
in No. 1 contracted typhoid fever--elsewhere, it was believed. As a
matter of course, all his discharges were thrown into the common
privy. In this way for more than a fortnight the stream which passed
through it was daily fed with the specific excreta from the diseased
intestines of the patient. No further cases occurred until the latter
end of the third week or the beginning of the fourth week, when
several persons were simultaneously attacked by the same fever in all
four cottages. From first to last, the outbreak was confined to these
four cottages, and there was no other case of typhoid fever at this
time in the neighborhood.

[Footnote 35: _Typhoid Fever: Its Nature, Mode of Spreading, and
Prevention_, by William Budd, M.D., F.R.S., London, 1873.]

The mattrass used by typhoid-fever patients, their bed-linen and
clothes, have each been the medium by which the disease has been
communicated to others. This is, as has already been pointed out,
unquestionably due to the fact that these articles are generally
soiled by their discharges, and that time has been allowed for the
latter to acquire infective properties. It seems not improbable that
the few cases in which the disease appears to have been contracted
from the dead body may be explained in the same way. The statistics of
the London Fever Hospital show that laundresses are more liable to
contract typhoid fever than the immediate attendants upon the sick.
This liability is greatest in those cases in which the bed-linen and
clothes of patients are not immediately disinfected after use.
According to Budd, the sputa in cases of typhoid fever where
bronchitis is excessive may sometimes contain the germs of the
disease, and mentioned a case in which he believed they were the means
by which the disease was propagated.

The question naturally arises here, whether this is the only way in
{254} which the disease can originate. This is a subject which has
given rise to a good deal of controversy, and therefore demands some
consideration at our hands. On the one hand, it is argued that typhoid
fever never occurs in the absence of the specific poison or germ of
the disease, and that this is contained principally, if not wholly, in
the alvine dejections. On the other hand, it is contended that it may,
and often does, originate spontaneously, and that all that is
necessary to produce it is the presence of decomposing fecal or other
organic matter, and the consequent contamination of the food, drink,
or atmosphere. Both of these views have found able advocates. Among
the upholders of the latter view is Murchison, who cites the histories
of several outbreaks of typhoid fever which occurred in localities
which had not been visited by it for many years, and which, after a
careful investigation of all the circumstances attending them, he was
forced to conclude had no connection with any previous case of the
disease, and could only be explained by admitting that it might
occasionally have an independent origin. Among the more remarkable of
these outbreaks is the following, which we give in Murchison's own
words:

"In August, 1829, 20 out of 22 boys at a school at Clapham within
three hours were seized with fever, vomiting, purging, and excessive
prostration. One other boy, aged three, had been attacked with similar
symptoms two days before, and had died comatose in twenty-three hours;
another boy, aged five, died in twenty-five hours; all the rest
recovered. Suspicions were entertained that they had been poisoned,
and a rigorous investigation ensued. The only cause which could be
discovered was, that a drain at the back of the house, which had been
choked up for many years, had been opened two days before the first
case of illness, cleared out, and its contents spread over a garden
adjoining the boys' playground. A most offensive effluvium escaped
from the drain, and the boys had watched the workmen cleaning it out.
This was considered to be the cause of the disease by Latham and
Chambers, and by others who investigated the matter, and also by Sir
Thomas Watson. The morbid appearances in the two fatal cases were
described as like those of the common fevers of this country. Peyer's
patches and the solitary glands of the small and large intestines were
enlarged like 'condylomatous elevations,' and in one case the mucous
membrane over them was slightly ulcerated. The mesenteric glands were
enlarged and congested."

"A remarkable instance of a circumscribed outbreak of fever was
recorded by Sir R. Christison in 1846. It occurred in an isolated
farm-house in the thinly-peopled county of Peebles, N.B. Every one of
the fifteen residents was seized with fever, and three died. Many of
the servants who worked during the day at the farm were also affected,
but none communicated the disease to their families who did not visit
the farm. There was no evidence that the disease was imported from
without, and the only explanation of the outbreak was, that the drains
and sewers were found all closed and obstructed with the accumulated
filth proceeding from the privies and farm-yard, the effluvia from
which was very offensive."

"About Easter, 1848, a formidable outbreak of fever occurred in the
Westminster School and the Abbey Cloisters, and for some days there
{255} was a panic in the neighborhood respecting the 'Westminster
fever.' No case of fever had occurred in the Abbey Cloisters for three
years, and there was no evidence of its having been imported. Within
little more than eleven days it affected thirty-six persons, all of
the better class, and in three instances it proved fatal. Shortly
before its first appearance there occurred two or three days of
peculiarly hot weather, and a disagreeable stench, so powerful as to
induce nausea, was complained of in the houses in question. It was
found that the disease followed very exactly in its course the line of
a foul and neglected private sewer or immense cesspool, in which fecal
matter had been accumulating for years without any exit, and into
which the contents of several small cesspools had been pumped
immediately before the outbreak of fever. This elongated cesspool
communicated by direct openings with the drains of all the houses in
which it occurred; the only exception was that of several boys, who
lived in a house at a little distance, but who were in the habit of
playing every day in a yard in which there were several gully-holes
opening into the foul drain."

The following cases would seem, however, to furnish stronger evidence
in favor of the occasional spontaneous origin of typhoid fever than
any of those referred to by Murchison. The first is recorded by P.
Herbert Metcalfe,[36] and occurred in Norfolk Island in the Pacific
Ocean, 400 miles from the nearest inhabited land. The patient was a
gentleman who had come from England four months previously. To
Metcalfe's certain knowledge, there had been no typhoid fever on the
island for fifteen months. Three years previously a man is reported to
have died of it, and in 1868 there had been an epidemic of fever, but
he could not ascertain of what kind. Upon inquiry, he found that his
patient had been drinking water from a well which had the reputation
of being unclean, and that he was the only person who had done so. He
also found that at a distance of seven feet there was an open sewer,
and that just opposite to the well much of the sewage-water became so
stagnant as to form an offensive cesspool. The well was cleaned out,
and at the bottom of it were found four feet of stinking sewage mud,
the skeleton of a duck, a pig's jaw, etc. The well was so situated
that had there been any typhoid fever previously to this case the
water could not have been contaminated by the specific poison, as the
above-named sewer only conveyed water from the kitchen, which is a
building detached from the dwelling-houses of the mission, and is far
from and on a higher level than the open closets in use.

[Footnote 36: _British Medical Journal_, Nov. 6, 1880.]

In the second case, which is reported by R. Bruce Low,[37] Medical
Officer of Health, Helmsley, Yorkshire, occurred in a lad who had not
been away from his home for months. No stranger had visited his house,
and there was no fever in the district, the last case having occurred
eight months previously in a sequestered valley eight miles away. The
patient's habits and those of his family were revoltingly dirty. The
garden privy was in bad repair, the filth level with the seat, and the
smell from it very offensive. Thirty years before there had been five
cases of slow typhus in the house. In his remarks on this case Low
says: "This case did not owe its origin to direct infection, and the
question naturally arises, was this a case originating de novo, or had
the poison {256} been due to infection in some way or another from the
cases which occurred thirty years previously?"

[Footnote 37: _Brit. Med. Jour._, 1880.]

There can be but little doubt that in many of the cases cited by
Murchison as instances of the spontaneous origin of typhoid fever
there was an introduction of the germs of the disease from without. At
all events, the evidence to the contrary is by no means convincing.
For example, in the account of the outbreak at the Westminster School
it is expressly stated that "the contents of several small cesspools
had been pumped before the outbreak of the fever" into the large
cesspool, the emanations from which it was believed had caused the
fever. It does not seem that it was positively ascertained that none
of these small cesspools had been used by a typhoid-fever patient, or
that typhoid stools had not found their way into them in some other
way. Moreover, in diseases generally admitted to be contagious it is
not always possible to ascertain positively the source of infection in
a particular instance. But after the elimination of all doubtful cases
there yet remains a certain number in which it is reasonably certain
that there has been no recent importation of the typhoid-fever germs,
as in the case which is reported by Metcalfe and which occurred on
Norfolk Island, and in that recorded by Low. The assumption does not
seem an unwarranted one that in these cases the poison of the disease,
which had been present before in a latent condition, had been suddenly
called into activity by favoring influences. The following observation
of Von Gietl[38] shows the length of time typhoid-fever stools may
retain their infective properties: "To a village free from typhoid an
inhabitant returned suffering from the disease, which he had acquired
at a distant place. His evacuations were buried in a dunghill. Some
weeks later five persons, who were employed in removing dung from this
heap, were attacked by typhoid fever; their alvine discharges were
again buried deeply in the same heap, and nine months later one of two
men who were employed in the complete removal of the dung was attacked
and died." If we assume--and there is no reason to doubt that this
point was fully investigated by Von Gietl--that the patient in the
latter case had not been otherwise exposed to the causes of the
disease, the observation shows that the stools in typhoid fever retain
their virulence for nine months. If for nine months, why may they not
do so for a much longer period--for as many years, for example? No
probability is violated by this hypothesis. On the contrary, it is in
full accordance with what we know of some of the lower forms of life,
and will serve to explain many outbreaks of the disease which would
otherwise be inexplicable--for example, the outbreak at Clapham
referred to by Murchison. Admitting that the disease in this instance
was really typhoid fever--and this has been denied by some observers,
among whom is Sir Thomas Watson--the assumption does not seem an
unwarrantable one that the germs of typhoid fever had been present in
this choked-up drain long before it was cleared, but that in
consequence of their exclusion from the air their infecting power was
at a minimum. It was, on the contrary, much increased when the
contents of the drain were exposed to the vivifying influence of the
atmosphere.

[Footnote 38: Quoted by Cayley, _Brit. Med. Jour._, Mar. 15, 1880.]

On the other hand, it is alleged that an individual may be exposed to
the direct emanations of sewers or of foul privies, or even drink
water {257} contaminated by leakage from them, without contracting
typhoid fever, so long as they do not contain the specific germ of the
disease. Every physician in large practice, either in the city or
country, can call to mind instances in which the air of houses or the
water-supply has been polluted in this way, and yet no typhoid fever
has occurred. Let, however, the specific cause of the disease be
introduced from without, and this immunity almost invariably
disappears. There is no reason to believe that the contamination of
the water used by the family which suffered in the outbreak of the
disease which has been already referred to as having come under my own
observation last year was of recent origin. On the contrary, there was
evidence to the contrary, and yet no disease occurred until it was
imported by a member of the family who was in the habit of making
frequent visits to the city. Even more strongly corroborative of this
view is the history of the epidemic reported by Ballard, in which milk
was the medium of communication. The water which had been used with
impunity to wash the milk-pans, or perhaps to dilute the milk, became
a source of danger only after the occurrence of the disease in the
family of the dairyman.

Several epidemics of typhoid fever have been recently reported in
which the disease appears to have been caused by the use of the flesh
of diseased animals or of meat in a condition of putrefaction. In some
of these the symptoms were rather those of irritant poisoning than of
typhoid fever, and consisted principally in violent vomiting and
purging coming on very shortly after the ingestion of the unwholesome
food. There yet remains a certain number in which the symptoms cannot
be thus explained.[39] One of the most remarkable of these occurred in
1878 at a festival which was held at Kloten, a place about seven miles
north of Zurich, of which the following is a condensed description:
Out of 690 persons who sat down to the collation, 290 were taken ill;
378 other persons, who did not attend the festival, but who partook of
the meat provided for it, were also affected. In addition these, 49
secondary cases occurred--_i.e._ of persons who subsequently became
affected without having eaten of the meat. All other sources of
infection could be certainly excluded, as Kloten was quite free from
typhoid fever at the time, and as it was clearly shown that the water
was not the cause of the outbreak. All the visitors at the festival
who ate no meat escaped, as did also several persons who drank wine to
excess and subsequently vomited. The period of incubation was short,
as in other epidemics arising from the same cause. Some of the people
were ill on the second day, with loss of appetite, nausea, headache,
pain and swelling of the belly, and slight fever. These cases were
slight, and generally ended in recovery. The greater number were
affected between the fifth and ninth days. The symptoms in these
cases, which usually ran a rapid course, and generally ended in
recovery, were chills, fever, diarrhoea, great prostration, frequently
violent delirium, and also profuse intestinal hemorrhage. The
rose-colored eruption was present in almost all of them, and in a few
the taches bleuatres were detected. On post-mortem {258} examination
the characteristic appearances of typhoid fever were found. With
regard to the meat supplied, the following facts were ascertained:
Forty-two pounds of veal were furnished by a butcher at Seebach, taken
from a calf which appears to have been at the point of death when it
received the coup de grace from the hands of the butcher. All the
flesh of the animal was sent to supply the festival at Kloten, but the
liver was eaten by an inhabitant of Seebach, and he was attacked by
typhoid fever. The brain was sent to the parsonage at Seebach, and all
the household became affected by the same disease. It was also
ascertained that another of the calves was diseased. The veal from
this calf had been kept fourteen days, and was in a decomposed state.
All the meat was placed together in the meat-receptacle of the inn at
which the festival was held. This receptacle was in a horribly filthy
state, and Cayley thinks there can be no doubt that the putrefying
flesh of this last calf, together with the state of the receptacle,
would rapidly excite decomposition in the whole supply.

[Footnote 39: _On Some Points in the Pathology and Treatment of
Typhoid Fever_, by William Cayley, London, 1880; also Prof. Huguenin,
_Schmidt's Jahrbuch_, from _Schweiz. Corr. Bl._, viii. 15, 1878; Carl
Walder, _Schmidt's Jahrbuch_, from _Berl. klin. Wochenschr._, xv. 39,
40, 1878; George R. Shattuck, M.D., Supplement to _Ziemssen's
Cyclopaedia_, New York, 1881.]

Geissler, it is true, doubts whether the epidemic above described was
really typhoid fever, and points out that the symptoms occurred too
soon after the ingestion of the diseased meat, and reached their full
development too rapidly. The cases were also accompanied by more pain
in the abdomen than is generally met with in typhoid fever. The
proportion of recoveries also appears to have been unusually large.
Unquestionably, the patients in the Kloten epidemic were in a large
number of instances simply suffering from the action of an irritant
poison; but the presence of the characteristic lesions of typhoid
fever in some of the fatal cases renders it certain that this disease
also existed in the village at the same time.

In the report of this epidemic it is not stated that either of the
calves which furnished a part of the meat for the entertainment were
suffering from typhoid fever at the time they were slaughtered. It is
now known positively that this animal is liable to be attacked by this
disease, and a certain number of cases are on record in which the
eating of the flesh of such animals has been followed by typhoid
fever.[40] That it does not oftener occur from this cause is probably
due to the fact that a certain time must elapse before the flesh of
such an animal acquires infective properties, and that it is usually
used as food before this has been allowed to pass.

[Footnote 40: _Medical Times and Gazette_, Feb. 8, 1879, p. 149, from
_Berl. klin. Wochenschrift_, No. 39, 1878.]

Ludwig Letzench[41] asserts that he has produced some of the
intestinal appearances of typhoid fever, as well as a high degree of
pyrexia, in rabbits by the subcutaneous injection of the sputa and
stools of typhoid fever patients.

[Footnote 41: _Arch. f. exper. Pathol. u. Pharmak._, 1878 and 1881.]

THE BACILLUS TYPHOSUS.--From what has preceded, it will be seen that
the writer is disposed to range himself with those who hold that the
exciting cause of typhoid fever is an organized germ, or, in other
words, a contagium vivum. Although this view cannot be regarded as
positively proven as yet, it has recently received some support
through the investigations of Klebs, Eberth of Zurich, and others,[42]
who believe that they {259} have found in the bodies of those who have
died of typhoid fever a micro-organism peculiar to that disease.

[Footnote 42: Klebs (_Philadelphia Medical Times_, Dec. 3, 1881, from
_Archiv fur experimentelle Pathologie und Pharmakologie_, Bd. xiii. H.
5 and 6) claims that he has proved "that there exists in typhoid fever
a separate and distinct bacillus--the _Bacillus typhosus_; that it
undergoes certain transformations, consisting at first of little rods
and small fine threads, containing a spore in the centre and often at
the end, which spores divide off and form new bacilli. It later
assumes a larger thread-like form, twisted at the end, and frequently
taking a beautiful spiral shape; that the bacilli are observed first
in the masses of epithelial cells which accumulate in the alimentary
tract or in the air-passages; that they later penetrate the tissues,
and are carried along by the blood-vessels and the lymphatics, and
form a large network among the tissues they invade; that under a
certain procedure, which never causes this same staining in any other
living organism or tissue, they appear of a blue color; that they are
found only in enteric fever, in which disease every part of the human
body is the seat of masses of these bacilli, their quantity
corresponding exactly with the severity of the symptoms; and that they
produce, when carried into the system of animals, exactly the same
disease with the same morbid alterations as in men." He says, further,
that "the Bacillus typhosus enters the system by the respiratory
passages and by the alimentary canal. This is the cause that in some
cases of typhoid fever almost no abdominal symptoms are present, but a
low form of pneumonia, developing from the very beginning, so that the
lung seems alone to bear the brunt of the disease." He has found these
bacilli in greatest numbers in Peyer's patches.

Eberth (_British Medical Journal_, Nov. 26, 1881, from _Virchow's
Archiv_, Bd. lxxxi. and lxxxiii.) has shown that in typhoid fever the
intestinal mucous membrane, the mesenteric glands, and the spleen
contain rod bacteria, differing, as he believes, from organisms found
in the body in other conditions (among others in phthisis with
extensive ulceration of the intestinal mucous membrane). In seventeen
cases of typhoid these bacilli were found in six and wanting in
eleven. In the six cases the number of bacilli were in inverse
proportion to the duration of the disease. They were not found in the
spleen in the cases of the longest duration, and only scantily in the
mesenteric glands. These bacilli appear not to differ in shape and
size from the ordinary rod bacteria, but Eberth believes that they
differ from them in their small capacity for taking on the staining of
haematoxylon, methyl-violet, and Bismarck brown.

Wernich's views (_Vjhrschr. f. Off. Geshpfl._, xiii. 4, p. 513, 1881)
in regard to the nature of the Bacillus typhosus differ from those
held by the two authors just quoted. He regards the specific Bacillus
typhosus as nothing but the ordinary Bacillus subtilis of the large
intestines, which under certain circumstances acquires the power to
accommodate itself to the small intestines, to undergo a higher
development and to become the exciting cause of disease.]

PERIOD OF INCUBATION.--The conditions under which typhoid fever occurs
in large cities render it difficult, if not impossible, to arrive at a
definite conclusion as to its period of incubation. Occasionally,
however, the time which has intervened between the exposure to the
cause and the invasion of the disease may be ascertained with
precision in the outbreaks which occur in small towns or in isolated
country-houses. Under these circumstances it has been found to vary
within very wide limits. In the three cases related by Griesinger the
attack began the day after exposure to the infection, and in the
outbreak at the school at Clapham, referred to by Murchison, twenty
out of twenty-two boys were seized with the disease within four days
of exposure to the causes. Other instances of a similar character are
on record. In cases like the above the rapidity with which the attack
follows upon exposure to the cause is no doubt due to the intensity of
the poison--a view which is to a certain extent at least supported by
the fact that the invasion of the disease under these circumstances is
very apt to be abrupt; the attack being often ushered in with vomiting
and purging or with grave cerebral symptoms. Sometimes, indeed, the
gastro-intestinal symptoms have been so violent as to have given rise
to suspicions of criminal or accidental poisoning. In the majority of
cases, however, the period of incubation is probably very much longer
than in those above referred to. In the outbreak which recently
occurred in a farm-house about seven miles distant from {260}
Philadelphia, the history of which has already been given in detail,
the second case began three weeks after the first, the other six
following in rapid succession. In the celebrated epidemic which
occurred at Lausen in Switzerland in 1872, and which is referred to by
Cayley,[43] the first ten patients were attacked within three weeks of
the time when the contamination of the spring which supplied the
village must have taken place, and these ten cases were followed in
the course of nine days by fifty-seven others. In the town of Over
Darwen 1500 persons were seized with typhoid fever within three weeks
after a patient suffering from this disease was brought to a
particular house, the sewage of which was allowed to soak into the
ground through which the water-supply pipes of the town passed, and at
a point at which they were leaky. Lothholz observed in an epidemic
which occurred in the neighborhood of Jena that the average period of
incubation was three weeks, the shortest period eighteen days, the
longest twenty-eight days. Haegler found in three cases produced by
contaminated water a period of at least three weeks.[44] There are,
however, epidemics on record in which the period of incubation was
under two weeks, as, for instance, that of Basle, referred to by
Liebermeister, in which a few persons were attacked who had only been
in the city from seven to fourteen days. Cayley also refers to
localized outbreaks of the disease, as those of Calne and Nunney, in
which persons were attacked within fourteen days of their exposure to
the cause. C. J. C. Muller of Posen[45] says that the average period
of incubation of the disease is fourteen days; that it may be not more
than ten days, or, on the other hand, as long as from three to four
weeks; and that he has known a case in which it was thirty-four days.
Murchison believed that it was most commonly about two weeks, and
William Budd arrived at the conclusion, from the observation of a
large number of cases, that it varied from ten to fourteen days.

[Footnote 43: _Brit. Med. Jour._, Mar. 15, 1880.]

[Footnote 44: _Ziemssen's Cyclopaedia_, vol. i.]

[Footnote 45: _Neue Beitrage zur Aetologie des Unterleibs-Typhus_,
Posen, 1878.]

From this review of the opinions of various authors the conclusion
would seem to be justifiable that the period of incubation in typhoid
fever is usually between two and three weeks, but that in many cases
it does not exceed ten days, and in rare instances has unquestionably
been very much less. On the other hand, there are authentic cases on
record in which it is said to have reached, or even exceeded,
twenty-eight days. Unfortunately, we do not possess any reliable data
with which to decide the question whether it is shorter or longer when
the poison is imbibed with the ingesta than when it is inhaled. It
would seem, however, that there is a difference in the susceptibility
of different individuals to the poison of this disease, in many
persons a single exposure to the cause being sufficient to induce an
attack, while in others the disease is contracted only after repeated
exposure.

MORBID ANATOMY.--As a thorough knowledge of the morbid anatomy of
typhoid fever is absolutely necessary to a correct understanding of
its pathology, it seems to me better to deviate from the order usually
observed in systematic treatises and to proceed at once to a
description of the former, rather than to defer it, as it is usual to
do, until after the symptomatology of the disease has been discussed.

Rigor mortis is generally more marked and more prolonged than after
{261} typhus. Emaciation is often extreme in cases in which death has
taken place after the third week, especially if they have been
attended by much diarrhoea and fever. No traces of the characteristic
rose-colored eruption are found after death, no matter how profuse it
may have been during life. Sudamina, on the other hand, persist, and
discolorations of the dependent portions from settling of blood are
always present in the dead body.

The lesions of typhoid fever may be divided into two classes. The
first class includes certain changes in the glands of Peyer, the
solitary glands of the intestines, the spleen, and other lymphatic
structures of the body. These changes, which consist essentially in a
medullary infiltration of these glands, will be minutely described
presently. They are peculiar to the disease, and are just as
characteristic of it as the condition of the lungs and their membranes
found in pneumonia and pleurisy are characteristic of those diseases.
They are usually most developed in grave cases, but occasionally they
are slight and but little marked in cases in which the general
symptoms were severe. They therefore cannot be regarded as the sole
cause of the latter. It is more probable that they are themselves the
results of the local action of the typhoid poison, and bear somewhat
of the same relation to typhoid fever that the eruption in small-pox
does to that disease. The second class is made up of lesions which are
met with not only in this disease, but in other diseases accompanied
by high fever, and are therefore unquestionably the result of the
general process. They consist essentially of parenchymatous
degenerations of various organs and tissues, and are generally more
marked in typhoid fever because the pyrexia is not only of high grade,
but also of longer duration than in other diseases.

We shall first consider the lesions peculiar to typhoid fever. Among
the most important of these are the changes which occur in the
agminated and solitary glands of the intestines. These have been
usually described as passing through four stages, as follows: (1) the
stage of medullary infiltration; (2) the stage of softening or
sloughing; (3) the stage of ulceration; (4) the stage of
cicatrization. These stages are said to last almost a week, and
correspond to certain definite periods of the disease, but it is not
uncommon to find in the same intestine glands in two or more of these
stages. Indeed, the same gland may sometimes be found ulcerating at
one side while cicatrization is going on at the other.

In the first stage the agminated glands are enlarged, each patch
preserving its oblong shape, and being flattened on the surface and
elevated from half a line to two lines above the surrounding mucous
membrane, from which it is separated by an abrupt border, and which it
may in a few cases overhang like a fungous growth. The solitary
follicles are also swollen, and may vary in size from a hempseed to a
split pea. In very severe cases all the glands may be more or less
involved, but in mild cases the changes may be limited to three or
four of the patches of Peyer, although the solitary glands rarely
wholly escape. It is uncommon also for the latter to be alone
affected, but a few such cases have been reported. In these the mucous
membrane appears to be studded with pustules, and hence Cruveilhier
designated this variety as the forme pustuleuse. The mucous membrane
covering the affected glands is reddish-green in color, and that in
their immediate vicinity is {262} often injected. The changes above
described occur early in the disease--Murchison has seen them in two
cases in which death took place at the end of the first day--and they
are often well marked at the end of the third or fourth day. They are
usually limited to the glands in the lower part of the ileum, the
agminated glands being often found perfectly healthy four feet above
the ileo-caecal valve. In mild cases, indeed, the lesions may be
confined to those nearest to this valve. So, too, the changes in the
solitary glands may be confined to the last twelve inches of the
smaller intestine, but this is by no means universally the case, for
these glands are not only often found enlarged higher up in the small
intestine, but also occasionally in the caecum. The agminated glands
are sometimes found enlarged in the bodies of those who have died of
measles and of some other diseases, but the degree of enlargement is
rarely as great as in typhoid fever, and the further changes presently
to be described are never found except in the latter disease.

Under the microscope the medullary infiltration upon which the
enlargement of the glands depends is found to be due to proliferation
of the cellular elements. In the case of the agminated glands this
proliferation may be limited to the follicles or it may extend to the
intercellular tissue, and even to the adjacent mucous membrane. In the
former case the patches have a reticulated aspect; they are soft and
but little elevated. These are the plaques molles of Louis and the
plaques reticulees of Chomel. In the latter they are harder, smoother,
and more elevated. To this variety Louis has given the name of plaques
dures, Chomel that of plaques gauffrees. The morbid process is also
very apt to extend from the solitary follicles to the surrounding
mucous membrane.

In a large number of the glands in many cases, and probably in all of
them in the abortive form of the disease, the changes never advance
beyond the first stage, a restoration to their normal condition taking
place by colliquative softening.[46] The morbid material upon which
their enlargement depends breaks down into an oily debris which is
gradually absorbed. This retrograde process takes place faster in the
follicles than in the interfollicular tissue, and, as pigment is very
apt to be deposited in the depressions thus formed, the patches
acquire an appearance which has been compared to that of a recently
shaven beard. This appearance is met with, however, in other diseases,
and is therefore not peculiar to typhoid fever.

[Footnote 46: Rindfleisch, _Pathological Histology_, Sydenham Society
Translation, vol. i. p. 441.]

The description of the changes in these glands in the subsequent
stages of the disease which follows is taken mainly from Rindfleisch's
work on _Pathological Histology_.

In the stage of necrosis small portions of single Peyerian patches,
varying in size from that of a lentil to from three-quarters of an
inch to an inch and a quarter in diameter, assume a yellowish-white,
opaque tint instead of their former reddish and translucent aspect,
gradually become separated from the surrounding tissue by a sharp line
of demarcation, and then pass into a state of cheesy necrosis. Here
and there the same changes are observed to have taken place in the
solitary glands. When once this has occurred, recovery can only take
place by expulsion of the necrosed parts and consequent ulceration.
Necrosis of the glands {263} probably rarely occurs before the
beginning of the second week, but it has occasionally been observed
much earlier. Murchison reports cases in which he saw it as early as
the first and second days. The process usually involves the mucous
membrane only, but it may extend to the muscular and even to the
peritoneal coats.

In the third stage the dead parts are gradually thrown off, the
process of separation usually occupying several days. At first an
increased degree of congestion, followed by suppuration, is observed
at the edges of the sloughs, which before their complete detachment
may often acquire a yellow, green, or brown color from the imbibition
of bile. The ulcers which result correspond in size and form with the
sloughs. They are, therefore, in the case of the agminated glands
elliptical in shape, with their long diameter corresponding to the
axis of the intestine. Their edges are swollen and overhanging, and
their floor is generally formed by the deepest layer of the submucous
connective tissue. They sometimes penetrate much more deeply, and may
even extend to the peritoneal coat, and thus give rise to perforation
of the bowel. The ulcers which result from sloughing of the solitary
glands are, as a rule, small and round. Murchison says that ulceration
may also be produced in the following way: The mucous membrane becomes
softened, and one or more superficial abrasions appear on the surface
of the diseased patch, which extend and unite into one large ulcer,
and this ulcer proceeds to various depths through the coats of the
bowel, and even to completed perforation, but Rindfleisch and other
recent German writers do not allude to this process.

The fourth stage, or that of cicatrization, usually commences with the
beginning of the fourth week. The swelling of the edges of the ulcers
gradually diminishes, and they become adherent to the tissues beneath.
The floor of the ulcers covers itself with delicate granulations,
which in course of time are converted into connective tissue. This is
ultimately coated with epithelium, but neither the villi nor the
glands of the mucous membrane are ever reproduced. The resulting
cicatrices may be recognized by the affected parts of the bowel being
thin and more translucent than in health, and may retain these
characters after the lapse of several years. They never give rise to
contraction of the bowel. The time occupied in the cicatrization of
each ulcer is said to be about two weeks. It occasionally happens that
while cicatrization is taking place at one end of the ulcer the
process of necrosis and ulceration is still going on at the other, so
that two or more ulcers may occasionally run together. This form of
ulcer may often retard recovery, and may sometimes end in perforation
of the bowel, even after convalescence seems to have been established.

The color and consistence of the mucous membrane of the caecum and
colon are in a large proportion of cases normal. In a few the membrane
is paler than in health, and in others it is of an ash-gray color. It
is also sometimes injected and softened. The solitary glands are
frequently enlarged and ulcerated, like those of the ileum. In the
former case the mucous membranes of the large intestine throughout its
whole extent, but especially that of the caecum and of the part of the
colon adjacent to it, is studded with minute elevations about a line
in diameter. When ulceration has occurred the ulcers are generally
round {264} and small, but they may occasionally be oval and of
considerable size. In the latter case their long diameter will
correspond in direction with that of the circular fibres of the
intestine. Murchison has known them to measure fully an inch and a
half in length. The colon is generally found much distended with
flatus.

Enlargement of the mesenteric glands from cellular hyperplasia and
hypertrophy of the connective tissue is constantly associated with the
morbid changes of the intestines just described. This enlargement
varies in different cases. In some the glands are not larger than a
pea or bean; in others they are said to have reached the size of a
hen's egg. It is always more marked in the glands which lie in the
angle between the lower end of the ileum and the caecum, and usually
bears some proportion to the intensity of the local disease; but it is
not to be regarded merely as a result of the local irritation, as it
has been observed in parts of the mesentery corresponding to perfectly
healthy portions of the intestine, and as the meso-colic glands have
been involved in cases in which the colon was free from disease. It
has, moreover, been observed in cases in which death has occurred very
early in the disease, and there can therefore be little doubt that it
is as much the result of the infective process as the infiltration of
Peyer's patches. In addition to being enlarged, if death has taken
place before the end of the second week the glands are hyperaemic and
of a purplish color. Later than this, when the sloughs become detached
from Peyer's patches, the swelling of the glands diminishes; they lose
their color and become pale, and if convalescence ensues they return
finally to their former healthy condition. Still, Murchison has seen
them shrivelled and pale or bluish for some time after convalescence.
In other cases the substance of the glands softens, with the formation
of a puriform liquid. If the softening only involves a small part of
the glandular structure, restoration to health may take place through
the absorption of this liquid. If it is more extensive, the whole of
the glands may break down into this puriform liquid, which, when the
patient recovers, undergoes caseous and finally calcareous
degeneration. Occasionally, a gland in this condition is the cause of
death from rupture and extravasation of its contents into the cavity
of the peritoneum.

The glands in the fissure of the liver, the gastric, lumbar, inguinal
glands, and indeed all the lymphatic glands in the body, have
occasionally been found swollen and congested, but their enlargement
cannot be classed among the specific lesions of the disease, but is
merely the result of a local irritation. Thus, Jenner says that in the
case of extensive ulceration of the oesophagus which came under his
observation there was marked enlargement of the oesophageal glands.
Liebermeister says that the lymphatic follicles which surround the
glands at the root of the tongue and in the tonsils are often affected
in the same way as the glands. In most cases after a time the swelling
disappears, but sometimes softening and rupture take place.

The spleen is almost invariably found to be increased in volume and to
have undergone changes in consistence and color. The degree of
enlargement and the other changes vary of course with the stage of the
disease at which death has occurred. The enlargement occurs with less
frequency in elderly than in young people, and is most marked at the
height {265} of the disease, the organ being then often twice or three
times its normal size, and in some cases, it is said, even larger.
Later, and especially during convalescence, the enlargement has
generally very much diminished. During the first ten days of the
disease the spleen is generally tense and firm, engorged with blood,
and dark red in color. Between the tenth and thirtieth days its
appearance remains the same, but the organ is found to be soft and
friable. During convalescence it becomes paler and firmer again, and
is often so shrunken in size that its capsule is relaxed and wrinkled.
Hemorrhagic infarctions are often met with. These sometimes soften and
break down into a puriform liquid, which may sometimes cause
peritonitis by rupture into the peritoneal cavity. Rupture of the
spleen is also said to have occurred from mechanical violence. These
changes are due in part to variations in the amount of blood, and in
part to a medullary infiltration of Malpighian corpuscles similar to
that which takes place in Peyer's patches and the glands of the
mesentery.

LESIONS WHICH ARE NOT PECULIAR TO TYPHOID FEVER, BUT ARE OF MORE OR
LESS FREQUENT OCCURRENCE.--The mucous membrane of the pharynx and
oesophagus may present a perfectly healthy appearance, but
occasionally it is congested and the seat of ulcerations which are for
the most part superficial. Sometimes, however, they have been found to
extend to the muscular coat, but they have never been known to
penetrate all the coats of these organs. Jenner refers to one case in
which there was extensive ulceration of the oesophagus, but usually
the number of ulcers is not large. In a few cases the mucous membrane
of the pharynx is coated with diphtheritic false membrane, and the
submucous tissue is infiltrated with serum and pus (Murchison).

The stomach and the upper part of the intestinal tract present no
lesions which are at all peculiar to typhoid fever. In a certain
number of cases congestion, softening, and even superficial
ulceration, of the mucous membrane of the stomach, and less frequently
of that of the duodenum, have been found. The mucous membrane of the
jejunum and of the upper part of the ileum is not usually much
reddened, and may be even paler than in health. In cases which have
been protracted it may be of an ashy-gray or slate color. The contents
of this part of the intestinal tract, which is rarely much distended
by flatus, do not differ materially in appearance or consistence from
the matter which generally composes the typhoid stool. The bowels may,
of course, be found filled with blood in cases in which a recent
hemorrhage has taken place. Invaginations of the small intestines,
unaccompanied by any evidences of inflammation, are occasionally met
with in the bodies of those who have died of typhoid fever. They are
produced, there is good reason to believe, during the death agony, but
are not peculiar to this disease, as they occur in many other
diseases.

Enlargement of the liver has been found in only a few cases after
death from typhoid fever. Softening is more common, but even this is
not a frequent result of the disease, for it was absent in 41 out of
73 cases examined with special reference to this point by Louis,
Jenner, and Murchison. The organ is occasionally hyperaemic, and
darker in color than in health, but it is oftener pale or normal in
appearance. Even, however, where it appears to be perfectly healthy to
the unassisted eye, {266} the microscope shows that its cells are very
granular and filled with oil-globules which often render the nucleus
indistinct or completely conceal it. When death has taken place at an
advanced stage of the disease many of the cells are found to be
completely broken down into a granular detritus. These changes are
usually proportional to the degree of pyrexia which has been present
during life. Rarer lesions of the liver are pyaemic deposits,
embolism, abscess, and emphysema.

The mucous membrane of the gall-bladder has been found to be the seat
of ulcers by Jenner and numerous other observers. It also occasionally
presents the evidences of catarrhal or diphtheritic inflammation. The
gall-bladder usually contains a pale watery liquid of a less density
than bile. When, however, inflammation of its lining membrane has
existed, its contents are mixed with pus and shreds of false membrane.

The mucous membrane of the larynx is sometimes found to have been the
seat of catarrhal or diphtheritic inflammation, and sometimes also of
ulceration. Jenner says that in typhoid fever laryngitis independent
of pharyngitis is extremely rare, but the German writers express a
different opinion. Griesinger estimated that laryngeal ulcers were
present in one-fifth of the fatal cases. Hoffmann found them
twenty-eight times in two hundred and fifty autopsies, and that the
ulcers had extended to and involved the cartilages in twenty-two out
of the twenty-eight cases. They are most commonly found in the
posterior wall of the larynx, and may involve the vocal cords. These
are often discovered after death in cases in which their existence was
not suspected during life. They were formerly supposed to be the
result of typhoid infiltration of the laryngeal glands, but careful
investigation has shown that they are the consequence of diphtheritic
inflammation of the mucous membranes. Inflammation and ulceration of
the trachea are comparatively rare. Hypostatic congestion and
infarction of the lungs are not uncommonly found after death from
typhoid fever, and less frequently the lesions of pneumonia. Evidences
of recent pleurisy are also discovered in a few cases. Acute miliary
tuberculosis of the lungs is more often met with as a sequela than as
a complication.

The changes in the brain and its membranes caused by typhoid fever are
few and unimportant, even in cases attended by severe nervous
symptoms. Those most frequently found are adhesions of the dura mater
to the inner surface of the cranium, injection or oedema of the pia
mater, congestive oedema, and sometimes softening of the brain and
effusion at the base of the brain. The microscopic changes do not
appear to have been carefully studied. Liebermeister says that the
gray substance of the cortical portion of the brain and of the
interior is sometimes of a rather yellowish-brown color, and that he
noticed besides diffuse yellow and blackish-brown spots in different
places, particularly in the corpus striatum and thalamus opticus. In
such places, he says, the microscope shows a diffuse yellow
coloration, a deposit of small brown pigment-granules, and also,
especially in the optic thalamus and corpus striatum, the
ganglion-cells thickly crowded with brownish or blackish
pigment-granules in such numbers as to conceal the outlines of many of
the cells. These changes Hoffmann,[47] who has specially studied them,
is inclined to place by the side of the parenchymatous degeneration of
other organs. {267} The ganglion-cells of the sympathetic ganglia are
said by Virchow also to contain an unusual amount of pigment.

[Footnote 47: Quoted by Murchison.]

The muscles are frequently the seat of marked changes in typhoid
fever. Their macroscopic appearances vary with the stage of the
disease at which they are examined. When death takes place in the
first or second week they are usually dark red or reddish-brown in
color, and very dry. If it is delayed until later, they "present a
peculiar fawn or yellow tint permeating the ordinary red in patches
and veins not unlike the appearance of veined marble." Their
consistence is also so much diminished that the finger may be readily
passed through them. Occasionally, pseudo-abscesses and hemorrhages
into the muscular sheath are found, and Dauve and B. Ball[48] report
cases in which, in addition to these changes, rupture of muscles had
occurred. Zenker, who was the first to call attention to them, ranged
the changes seen under the microscope under two heads: (1) granular or
fatty degeneration; (2) waxy degeneration. In the first variety the
transverse striae disappear and the sarcolemma appears filled with
finely granular matter. In the second variety the striated muscles
become, as it were, pervaded by a coagulating material which sets, and
in contracting breaks up the fibres into great numbers of short
waxy-looking lumps, not unlike a certain variety of casts of the
tubuli recti of the kidneys. When recovery takes place the affected
fibre is believed to be regenerated by a cell-growth within the
sarcolemma. These changes occur in most fevers, as typhus, small-pox,
scarlet fever, and are attributed by authors generally to the
hyperpyrexia which is a frequent accompaniment of these diseases.
Hayem, however, asserts that he has found them well marked in cases
not characterized by a high temperature, and that, on the other hand,
they are sometimes absent in cases where this has been present. The
waxy form of degeneration may affect all the striped muscles, but is
oftenest seen in the muscles of the abdominal walls, the adductors of
the thigh, the muscles of the diaphragm, and tongue.

[Footnote 48: _L'Union Medicale_, 1866, quoted by _Biennial Retrospect
of Medicine and Surgery and their Allied Sciences_, for 1865-66.]

The heart, in common with the other muscles of the body, suffers from
both the forms of degeneration above described, but the granular form
appears to be more common than the waxy. In protracted cases it is
usually much softened, and when thrown upon a plate no longer retains
its form. It has usually lost its normal color and acquired the tint
described by the French as feuille morte (faded leaf). Upon minute
examination the degeneration is found to have taken place in patches,
the diseased fibres being found alongside of others which have
scarcely undergone any alteration. These patches are especially common
in the papillary muscles of the mitral valve--a fact which explains
the occasional presence of systolic murmurs in typhoid fever. In
addition to the microscopic appearances of the muscles already
described, Hayem[49] has observed in his examinations of the heart a
cellular infiltration of the connective tissue and a proliferation of
the muscle nuclei. These changes are sufficient in his opinion to
establish the existence of myocarditis. The same observer thinks he
has also found evidences of the frequent occurrence of endoarteritis
in the multiplication of the cellular elements {268} of the internal
coat of the small arteries, which he has discovered under the
microscope.

[Footnote 49: _Lecons cliniques sur les Manifestations cardiaques de
la Fievre typhoide_, Paris, 1875.]

Some discrepancy of opinion exists in regard to the condition of the
blood in typhoid fever. Trousseau, for instance, speaks of it as being
profoundly altered and in a state of dissolution; Liebermeister says
that at the height of the disease the blood is very dark-colored, and
that after coagulation it presents a small and soft clot; and
Murchison, that a dark, liquid condition of the blood is rarer than in
typhus, and that fine white coagula are more common. Harley too has
frequently found firm colorless clots of fibrin in the heart and roots
of the great vessels in subjects dead in the third week of the
disease. Forget concludes from an examination "of one hundred and
twenty-three specimens of blood derived from patients in all stages of
the disease that an appreciable alteration of the blood in the several
periods of enteric fever cannot be accepted as a general fact; that
the blood is rarely altered in the first period; that the alteration
is more marked in proportion as the disease is more advanced; that the
alteration is not always in proportion to the gravity of the
disease."[50] I have myself seen the disorganization of the blood as
complete in severe cases of typhoid fever which have rapidly proved
fatal as in cases of diphtheria or of other malignant diseases. On the
other hand, in protracted cases and during convalescence the blood is
often thin and watery.

[Footnote 50: Quoted by Harley, Reynolds's _System of Medicine_, vol.
i.]

The kidneys are sometimes engorged with blood, sometimes pale and
flabby. Under the microscope the appearances are similar to those just
described as occurring in the liver, and it is therefore unnecessary
to refer to them more fully here. As a rule, the epithelium becomes
granular earlier and to a marked degree in the cortical than in the
tubular portion. The absence of albuminuria must not always be
accepted as proof of a healthy condition of the kidneys, as this
symptom has been wholly wanting in cases in which the organs have been
extensively diseased.

Analogous changes have also been observed in the salivary glands and
pancreas, except that, according to Hoffmann, a cellular proliferation
precedes the degenerative process.

CLINICAL DESCRIPTION.--The invasion of the disease is usually so
gradual that it is often impossible to obtain from patients exact
information as to the time of the beginning of their illness. Among
those who present themselves for treatment at the Pennsylvania
Hospital it is not uncommon to find that many have suffered for
several days, it may be as long as a week, or even longer, before
taking to their beds, from vague feelings of discomfort, from headache
more or less intense, aching pains in the back or limbs, or from
sensations of chilliness alternating with flashes of heat. In other
cases derangements of the digestive system are more prominent, such as
nausea, or even vomiting, diarrhoea, or irritability of the bowels.
Notwithstanding these symptoms, and the indisposition to exertion
engendered by them, they have frequently continued to follow their
usual avocations up to the time of their application at the hospital
for admission. There is generally, however, no difficulty in
recognizing at once the nature of their disease. Upon examination the
pulse is found to be frequent, the respiration accelerated, the tongue
furred, the skin hot and dry, and the abdomen tympanitic.

{269} Among patients whose position in life enables them to pay
greater attention to trifling symptoms than those who are compelled to
seek hospital relief, opportunity is frequently afforded to the
physician to study the disease at a period less remote from its
commencement. The symptoms it presents when seen as early as the
second day are generally of a very indefinite character. There may be
a feeling of malaise, headache with a tendency to giddiness, pain in
the back and limbs, a slightly coated tongue, thirst, and anorexia.
The patient may complain of chilly sensations alternating with flashes
of heat, but it will rarely be found that the attack has commenced
with a decided chill. Diarrhoea may also be present at this time, or
may not supervene until later. Even in cases in which it is absent the
bowels will generally act inordinately after the administration of a
gentle purgative. Occasionally, the attack begins with vomiting, but
this is not, in my experience, a frequent mode of commencement. If the
visit be made in the morning, the febrile symptoms will be little
marked, the pulse being only slightly accelerated and the temperature
being rarely more than from a half to a degree above the normal. In
the evening, however, the thermometer usually indicates a greater
elevation of temperature.

At subsequent visits the same symptoms are presented. It will be
observed, however, that the fever is decidedly remittent in character,
the evening temperature being always from a degree to a degree and a
half higher than that of the morning, while the temperature of each
succeeding day is a little higher than that of the day which preceded
it. The patient is restless and wakeful at night, or sleep, when
obtained, is unrefreshing and disturbed by dreams. He grows dull and
slightly deaf, and although able to answer questions intelligently
when roused, does so with an effort, and soon after lapses into his
former condition. Although obviously growing weaker every day, it is
sometimes difficult to get him to take to his bed. The diarrhoea
continues and increases in severity; the stools become watery in
character and ochrey-yellow in color; they may exceed six, or even
twelve, in the twenty-four hours. Epistaxis either consisting of a few
drops of blood only, or so profuse as to endanger life, may also occur
during the first week. Examination of the abdomen toward the middle or
close of the first week will almost always reveal the existence of
tympany and of tenderness and gurgling in the right iliac fossa, and
very frequently also of slight enlargement of the spleen. The urine at
this stage of the disease is dense, scanty, and of high color. The
tongue too will be observed to be more heavily coated than at first,
and to be dryish, the fur being disposed on the middle of the dorsum
of the organ, while the tip and edges are free from it and abnormally
red in color. Usually, toward the close of the first week, the pulse
will be found to be between 100 and 120 in frequency. It often,
however, does not attain this frequency, and in some cases does not
exceed 50 throughout the whole of the attack. At the same time, the
thermometer generally indicates a temperature of from 102 degrees to
104 degrees, and in bad cases even one much higher than the latter.

These symptoms are not pathognomonic, but Murchison regards their
existence in a young person as warranting the suspicion that he is
suffering from this disease. About this time, however, or, to speak
more accurately, usually from the seventh to the twelfth day, a new
symptom occurs {270} which is more characteristic. This is an eruption
of isolated rose-colored spots, the taches roses lenticulaires of
Louis, occurring principally upon the surface of the abdomen, but not
infrequently seen also upon the chest, back, limbs, and even,
according to some authors, upon the face. They are round in shape,
with a well-defined margin, usually about a line in diameter, but
sometimes considerably larger, slightly elevated above the surface,
and disappearing upon pressure, but returning when the pressure is
removed. They can almost always be found at this stage of the disease
if diligently sought for.

If the disease tends to run a severe course, all the symptoms become
aggravated toward the end of the second week. The tongue grows dry and
brown, the pulse more frequent, feeble, and markedly reduplicated in
character, the diarrhoea still more severe, and the fever higher than
before, with little or no tendency to remit in the morning. The
nervous symptoms also come into prominence. The headache may grow more
violent or may be replaced by increased dulness, which may sometimes
be so decided as to render it difficult to fully rouse the patient. At
other times delirium is a prominent symptom. This may only occur at
night, but not infrequently is observed during the daytime as well. It
is usually more active in character than that which accompanies
typhus. Trembling of the tongue and of the limbs is not uncommon at
this time. The urine becomes more abundant, paler, and less dense than
before. Even in cases characterized by symptoms as severe as those
above detailed some improvement is, however, often observed to take
place between the fourteenth and twenty-first days. The morning
remission becomes more decided, the evening temperature less high than
that of the preceding day; the stools lessen in number, and gradually
assume a more healthy appearance; the pulse diminishes in frequency
and gains in force; the tongue becomes moist, and shows a tendency to
throw off its fur; the trembling grows less marked; the dulness and
delirium lessen; and the patient falls into a refreshing sleep. In
other cases, in many of which recovery eventually takes place, there
is at this time, instead of an improvement, a still further
aggravation of the symptoms. The pulse becomes more feeble and
frequent; the tongue is not only excessively dry and brown, but
shrivelled and fissured; the lips and teeth are encrusted with sordes;
the stools contain shreds of membrane, and often blood; the subsultus
tendinum increases; carphololgia, or picking at the bed-clothes,
occurs. The prostration becomes so extreme that the patient frequently
slips down in bed from sheer weakness. The active delirium of the
previous stage is replaced by the low muttering form, or the patient
lies upon his back with his eyes half closed in a semi-unconscious
condition, from which he is with difficulty aroused, and which may
deepen into coma. Occasionally, however, the active delirium
continues, and is associated with an obstinate wakefulness; the urine
and feces are passed involuntarily, or, with an apparent incontinence
of the former, there may be retention, which is very apt to be
overlooked. If these symptoms continue for any length of time,
bed-sores may form not only over the sacrum, but on other parts
subject to pressure, and the patient, worn out by long-continued
suffering, dies from exhaustion.

Occasionally, in the midst of these symptoms, and sometimes even in
cases in which the condition is not so alarming, prostration
approaching {271} collapse, without obvious cause, suddenly
supervenes. The pulse becomes a mere thread, the surface is bathed in
a clammy sweat, and the temperature is found to have fallen from four
to seven degrees, and in some cases even more. These symptoms almost
always indicate that intestinal hemorrhage has taken place, and are
followed by the discharge of blood either in the course of a few hours
or not until a day or two subsequently. If the hemorrhage be moderate
in amount, and does not recur, reaction usually takes place in a short
time; but if, on the other hand, it is profuse or frequently repeated,
death may occur, either immediately or later, as the result of the
exhaustion it has induced. Very much the same set of symptoms attend
the occurrence of perforation of the bowel, an accident which is also
liable to happen in the course of typhoid fever, but which may
generally be distinguished from intestinal hemorrhage by its being
accompanied by a sharp pain in the abdomen, which is frequently so
severe as to cause the patient to cry out, by its not being attended
with the same reduction of temperature, and by the absence of blood in
the discharges. In a day or two all doubt will be set at rest, if the
case be one of perforation, by the occurrence of general peritonitis.

A fatal termination is by no means the usual result, even in cases in
which the disease has assumed its worst features. Indeed, it may be
said that there is no condition in typhoid fever so grave that
recovery from it is impossible. Many authors would make perforation of
the bowel an exception to this general rule, but there are
observations on record which would seem to show that this accident is
not invariably fatal. Even in cases in which the patient has lain
helplessly on his back in a semi-unconscious or comatose condition,
passing his discharges under him, the physician will often be
gratified to find at one of his visits some evidence of improvement,
trifling as it will probably be. It may be only a slight change of
position, an inconsiderable fall of temperature, or a scarcely
appreciable moistening of the tongue; but these changes, insignificant
as they apparently are, are sufficient to indicate to the practised
eye of the observant physician the approach of convalescence. Next day
there will be a still further reduction of temperature, a more decided
moistening of the tongue, a sensible diminution of the nervous
symptoms, and a reduction in the frequency of pulse. In this
condition, however, as may be readily imagined, convalescence may be
retarded by numerous accidents, and life may hang trembling in the
balance for several days, or even weeks, before it is fully
established. It is not necessary to recount here the various steps by
which a return to health is reached, as they are essentially the same
as those which mark the convalescence of the less severe variety of
the disease, and have already been fully referred to in the
description of that form.

But even after the establishment of convalescence, and after the
patient has been free from fever for several days, febrile attacks
lasting for a day or two, or even longer, may occur as the consequence
of very slight causes, such as undue excitement, or fatigue of any
kind, or the immoderate indulgence of the appetite, which in this
condition frequently needs to be restrained. These attacks are usually
spoken of as recrudescences of fever, and do not differ materially
from attacks of irritative fever occurring under other circumstances.
They usually subside under appropriate treatment with the removal of
their cause, but leave the patient somewhat {272} weaker than they
found him. In other cases, it may be a week or ten days after the fall
of the temperature to the normal, and frequently at a time when all
danger seems to have been passed, a true relapse of the disease
occurs. In this, of course, all the symptoms of the primary attack are
reproduced, including even the eruption of rose-colored spots. The
temperature usually, however, attains the maximum more rapidly, and
the duration of the fever is generally shorter, than that of the
original attack. A second relapse is also not very uncommon, and even
a third may occur. Various complications and sequelae also occur in
the course of typhoid fever, which will be referred to fully
hereafter.

Another form of the disease, which it may be well to allude to briefly
here before closing the general description of the disease, is the
abortive form. In this variety the attack begins and runs its course
up to a certain point, including often even the occurrence of the
eruption, as it does in the majority of cases; but at a period which
varies between the seventh and fourteenth day the symptoms suddenly
subside and the patient rapidly convalesces. In some cases it may be
difficult to distinguish this form from an attack of simple continued
fever, and, in fact, in cases in which the eruption is absent it will
be impossible, unless other cases of typhoid fever have occurred in
the same house or family, or unless the patient has been unmistakably
exposed to the influences under which the disease arises.

In a few cases the disease begins abruptly with a chill, intense
headache, or with gastro-intestinal symptoms, which have in rare
instances been so violent as to have suggested to the mind of the
attending physician the possibility of corrosive poisoning. This,
according to Chomel, is the most frequent mode of commencement, but
his experience on this point is opposed to that of the great majority
of observers.

       *       *       *       *       *

I shall now proceed to describe in detail some of the most important
of the symptoms presented by the disease.

Even in the beginning of an attack of typhoid fever the face has a
listless and languid expression, although the eyes are usually bright
and the pupils dilated. In mild cases no further alteration of the
physiognomy than this may be noticeable throughout the whole course of
the disease, but in bad cases, when the typhoid condition is fully
developed, the expression becomes dull and heavy. There is, however,
never the general suffusion of the face seen in typhus. On the
contrary, the face is often pallid, or there is at most a
circumscribed flush on one or both cheeks, which is most marked during
the exacerbations of fever or after the administration of food and
stimulants. During convalescence the effects of the long illness are
fully visible in the face.

Prostration, or loss of muscular strength, is present from the
beginning in a large number of cases of typhoid fever, but is
generally not so marked in the early stages as in typhus fever. It is
usually most intense in grave cases, but to this rule there are
numerous exceptions. It is not rare to find patients, in whom the
other symptoms are severe, able to sit up in bed, and even to rise to
stool, throughout the attack. Bartlett records a case in which the
patient did not confine herself to bed until the occurrence of
perforation, and I have had under my care a man who, supposing he was
suffering only from a slight diarrhoea, performed the duties {273} of
a nurse in a military hospital until two days before his death,
although the autopsy showed very extensive ulceration of the
intestine. Several cases have come under my care in the second week in
which patients have walked a considerable distance to make application
for admission to a hospital. Generally, however, the prostration
becomes extreme in the third and fourth weeks of bad cases, the
patient lying helplessly on his back, and frequently slipping down in
bed from sheer weakness.

Epistaxis may occur at any stage of typhoid fever, but is most common
in the forming stage. Observers differ in opinion in regard to its
frequency. Murchison noted it in only 15 of 58 cases, and gives it as
his belief that it is more common in France than in England or this
country. Flint found that it had occurred in 21 only of 73 cases, and
Jenner in 5 of 15 fatal cases. On the other hand, Bartlett says that
it is quite a common symptom, and Wood and Gerhard, from the frequency
with which they had met with it in the beginning of the disease, were
accustomed to regard its presence as of importance in a diagnostic
point of view. Part of this divergence of opinion is probably due to
the fact that it is usually small in amount, and therefore very apt to
be overlooked. I have in many cases, after having been told there had
been no epistaxis, found the evidence of it upon the fingers or
bed-clothes of the patient. It may, however, be so profuse as to
endanger life and render necessary the use of the tampon. Except in
the latter case it is without influence upon the course of the
disease.

The skin may be almost constantly dry as well as warm throughout the
whole course of the fever in a small proportion of severe cases. But,
on the whole, perspiration occurs with greater frequency in typhoid
fever than in any other acute disease, unless it be rheumatism. It
takes place most commonly at night after the evening exacerbation, or
in the morning when the patient awakes from sleep, but it is not very
rare to find the skin clammy at other times. The sweating is usually
general, but in a few cases it is local only. When colliquative, it is
frequently exhausting, and is then a grave symptom. It is sometimes
prolonged into convalescence, when it is not only annoying, but in
consequence of the prostration it induces may sometimes retard the
restoration to health.

I have never been able to satisfy myself that any peculiar odor is
given off by the skin in typhoid fever, and most observers make a
similar statement. Chomel, however, asserted that the perspiration has
a strong acid odor, and Bartlett agreed with Nathan Smith in thinking
that typhoid fever patients exhale a peculiar odor, not pungent and
ammoniacal, like that of typhus, but "of a semi-cadaverous and musty
character," which is especially noticeable during the later stages of
severe and fatal cases.

The eruption is one of the most characteristic symptoms of the
disease. Indeed, in many cases, without it the diagnosis would be
impossible. It is rarely absent in a well-developed case. Murchison
says that it was noted in 4606 cases only out of 5988 admitted into
the London Fever Hospital in twenty-three years, but admits that it
would probably have been found in some of the others if it had been
properly looked for. Wood says that he has seldom met with cases in
which it was absent. It is oftener absent in children than adults--a
circumstance which makes the diagnosis of the disease in the former
often a matter of great difficulty. It consists of isolated
rose-colored spots, slightly elevated above {274} the surface,
circular in form or nearly so, having well-defined margins, usually
about a line in diameter, but sometimes varying from half a line to
two and even three lines in diameter, and disappearing on pressure, to
return when the pressure is removed. They are generally first observed
some time between the seventh and fourteenth days, but cases are on
record, especially in children, in which they are said to have
appeared much earlier, and others in which they could not be
discovered until the twentieth day. In the latter cases, however, it
is not improbable they had really been present at an earlier period,
but had escaped detection. The eruption occurs in crops at intervals
of three or four days, each spot lasting from three to five days, and
the whole duration of the eruption being usually from ten to twenty,
and varying of course with the severity of the attack. It may continue
to appear as late as the twentieth day, and in cases of relapses very
much later. Spots are sometimes seen on the abdomen or elsewhere after
the subsidence of fever, and whenever seen indicate that the diseased
process is not at an end. They are usually scattered over the lower
part of the front of the chest and the abdomen, but are also not
infrequently met with upon the back, and if they are not found upon
the abdomen, the patient should be gently turned upon his side and
this part of his body carefully examined. When very abundant they are
often also seen upon the extremities, and occasionally even upon the
face. Wood has seen them abundant on the upper and inner part of the
thigh, and confined to that place. When tardy in making their
appearance, they may often be brought out by application of a mustard
plaster or by that of heat in any form; and it is probably, therefore,
owing in large measure to the warmth of the bed that they are often so
fully developed upon the back. In number they may vary from two or
three to several hundred. In one case Murchison counted one thousand,
and in three cases which came under my care in the winter of 1881-82
the body was so thickly covered by spots of an unusually large size
that when I first saw the patients I directed them to be isolated
under the fear that the disease would prove to be typhus fever. When
very numerous the edges of two or three of the spots may run together,
giving the eruption an irregular character. No relation between the
copiousness of the eruption and the severity of the disease has ever
been proved to exist. While the prevailing impression, therefore, that
cases in which the eruption is freely developed are apt to be of a
mild character, is true in many instances, it is by no means so in
all. The three cases above referred to all ran a severe course, and
one of them proved fatal. The spots disappear after death, and are
rarely converted into petechiae, but in bad cases I have seen purpura
spots, and even vibices, developed independently of them. Sometimes
the appearance of the eruption is preceded for a day or two by a
delicate scarlet rash, which Tweedie says resembles roseola and has
been mistaken for scarlet fever.

Sudamina, so called from their resemblance to sweat-drops, also occur
not infrequently in this disease. They are minute vesicles, often not
larger than a pin's head, but sometimes two lines in diameter, and
occasionally, in cases in which two or three have coalesced, much
larger. They usually contain at first a clear serum, which may,
however, subsequently become turbid, and when very minute must, in
consequence of {275} their transparency, be viewed obliquely to be
seen. Frequently, when they cannot be distinguished by the eye, they
are readily detected by the touch. They rarely occur before the
twelfth day, and often not before the close of the third week. Their
most usual seat is the neck, the folds of the axillae, and the groin,
but there is no part of the body except the face in which they may not
occur. They are most frequently seen in those cases attended by
profuse sweating, and are by no means peculiar to typhoid fever, but
are met with in other diseases--as, for instance, acute
rheumatism--which are attended by this symptom. They are generally
followed by branny desquamation of the cuticle in the position they
have occupied.

Spots of a delicate blue tint--the "taches bleuatres" of French
writers--are sometimes observed on the skin in cases of enteric fever.
They must be of infrequent occurrence in this country, for, although I
have looked carefully for them in every case that has come under my
care, I have rarely been able to detect them. According to Murchison,
"they are of an irregularly rounded form and from three to eight lines
in diameter. They are not in the least elevated above the skin, nor
affected by pressure, even at their first appearance. They have a
uniform tint throughout their extent, and they never pass through the
successive stages observed in the spots of typhus. Two or three of
them are sometimes confluent. They are most common on the abdomen,
back, and thighs." They are said in some cases to be distributed along
the course of the small cutaneous veins, and to occur most frequently
in cases which are mild. They are met with in other diseases, and
usually precede in appearance the characteristic eruption of typhoid
fever.

The hair is very apt to fall out after an attack of typhoid fever. The
nails suffer in their nutrition in common with other parts of the
body--a fact which may be recognized by the peculiar markings which
are found upon them after recovery, and to which attention has been
particularly drawn by Morris Longstreth in a paper in the
_Transactions_ of the College of Physicians of Philadelphia, vol.
iii., 3d Series.

The circulation is usually accelerated from the beginning of an attack
of typhoid fever. The degree of acceleration is commonly proportioned
to the severity of the other symptoms, and especially to the elevation
of the temperature, and is generally more marked in the evening than
in the morning. It is subject, however, to numerous variations, not
only in different cases, but even in the same case from day to day,
and even from hour to hour. Murchison refers to a case in which the
pulse sank to 37, and never exceeded 56 during the fever, although it
rose to 66 during the convalescence. I have never had the opportunity
myself of observing such an infrequent pulse in the febrile period of
the disease, but have had cases under my care in which the pulse often
fell below 60, and in which it never exceeded 80 until after the
commencement of convalescence. A comparatively infrequent pulse may
coexist with a high temperature. Thus, for example, a pulse of 80 was
noted in one of my cases at the same time that the thermometer showed
that the temperature was 105 degrees, and on another occasion in the
same case the pulse was 82 and the temperature 104-1/2 degrees. As a
rule, the pulse is more frequent in cases which terminate fatally than
in those which end in recovery; but to this rule there are numerous
exceptions. In eight of Louis's cases it never {276} went above 90,
and in some of my own it did not reach 100 on more than one or two
occasions. On the other hand, in mild cases the pulse may be
exceedingly frequent, reaching, and even exceeding in many cases, 120.
When the disease is prolonged and the prostration is extreme, a pulse
of from 140 to 150 is not uncommon. In the majority of cases which
have come under my care the pulse has varied in frequency from 80 to
120. In some cases the range has been between these two figures, in
others it has been very much less.

During convalescence the pulse usually gradually diminishes in
frequency, and may sometimes fall below the normal standard. I have
known it in a few instances to fall to 38, and have often met with
pulses ranging between 40 and 60 at this period. In other cases, on
the contrary, the pulse continues frequent during convalescence, or
readily becomes so after a slight exertion or excitement of any kind.
A slow pulse during convalescence has been in my experience most
frequent in men whose health previous to the attack was good, and a
frequent pulse in women and delicate men. If the convalescence is
retarded by a complication, the pulse will maintain its frequency
until this is removed.

The pulse will of course present other changes than those above
referred to. It is in the beginning firm and full, but after the first
week becomes small and compressible, and acquires the peculiarity
known as reduplication. Sometimes, when this is not well developed, it
will be rendered quite distinct by elevating the patient's arm.
Irregularity or intermission of the pulse, although not commonly
observed in this disease, occasionally occurs. The heart's action will
also be observed to grow feeble in the course of severe cases, and its
first sound indistinct, but neither of these changes is as marked in
typhoid as in typhus fever. Hayem asserts that in a certain number of
cases a systolic bellows murmur, with its point of greatest intensity
at the apex, is heard during the course or at the close of the second
week. This murmur is sometimes soft in the beginning, but becomes
harsh and intense later, or may have these characters from the start
to such a degree as to give the impression that endocarditis exists.
During convalescence an anaemic murmur is not infrequently present.

The respiratory movements are accelerated in typhoid fever, as they
are in all febrile conditions, independently of any disease of the
lungs, and their frequency is generally proportional to that of the
pulse. In looking over my records of cases I find that the former are
less liable to fluctuate from day to day than the pulse, and that when
the latter becomes abnormally infrequent they do not sink below the
standard of health. In several cases of which I have notes the
respiration was from 20 to 28, while the pulse was below 60, and in a
case referred to by Murchison the pulse was 42 at the same time that
the respirations, although no pulmonary lesion could be discovered,
were 48. The respiration is often, as in the case just alluded to,
very much accelerated when the most careful examination of the chest
will not lead to the detection of any disease there. This is sometimes
the consequence of very great tympanites, which, by interfering with
the descent of the diaphragm, gives rise to dyspnoea, but it may also
occur as a purely nervous phenomenon. The air expired by patients has
been examined, and has {277} been found sometimes, in the later stages
of the disease, to contain ammonia.

Bronchitis is so common an accompaniment of typhoid fever that
auscultation rarely fails to reveal its presence in some form or
other. In some cases there may be only slight harshness of the
respiratory murmur at the base of the chest, but in a large number of
cases the auscultatory signs will be sonorous, sibilant, and mucous
rales. The last named may be so numerous that I have known the disease
in the beginning mistaken for acute bronchitis, and even acute
phthisis, by accomplished diagnosticians.

Headache is one of the most constant symptoms of typhoid fever.
Bartlett says that it is rarely absent, Louis found it in all but 7 of
133 cases, and Jackson noted it in nearly all his cases. It is often
the first symptom of which the patient complains, and, when not
present at the beginning of the attack, makes its appearance soon
after. It is almost as common, although less severe, in mild cases as
in grave ones. It sometimes persists throughout the attack, but
oftener subsides at the close of the first week or toward the middle
of the second, or the patient may cease to complain of it in
consequence of the dulness which is very apt to supervene. It is
usually referred to the forehead and temples, but may extend over the
whole head. It is usually dull and heavy, but in a few cases is
throbbing. It is said by authors rarely to be severe, but I have known
it so intense and acute as to cause the disease at its commencement to
be mistaken for meningitis, and Jackson asserted that it is sometimes
so severe that local bloodletting, and even venesection, had to be
employed for its relief. It would appear to be as common in children
as adults.

The headache is sometimes accompanied by vertigo and dizziness, and
even by retraction of the head. Distressing pains in the back and
limbs may also occur, and in rare cases even contraction of the hands
and feet.

In the beginning of an attack of typhoid fever the patient usually
suffers from wakefulness and restlessness at night, and it
occasionally happens that the wakefulness becomes a distressing
symptom. But in a great many cases, sooner or later in the course of
the disease, drowsiness supervenes. In mild cases this symptom is late
in making its appearance, and is generally slight and evanescent, but
in grave cases it may come on as early as the eighth day, and when
once present may gradually become more profound until it deepens at
last into unconsciousness. It usually persists until the occurrence of
death or of convalescence, but may alternate with periods of delirium,
the delirium being more frequent at night and the somnolence by day.
It is as frequent in children as in adults. Occasionally, the
wakefulness of the earlier stage may reappear at the beginning of the
third week, and coexist with muttering delirium, or occasionally with
delirium of a more violent character. It then constitutes a most
unfavorable symptom, the patient frequently passing several days and
nights in incessant agitation, and sinking finally from exhaustion due
to want of sleep.

Some degree of mental hebetude is rarely absent, even in the mildest
cases of typhoid fever, and is usually among its earliest symptoms. It
may, however, be absent occasionally in cases which run a severe
course. It exhibits itself in the beginning in an indisposition to be
disturbed, a slight inability to fix the thoughts, or a loss of
memory. Generally, the {278} patient will be able at first, by an
effort, to rouse himself from this apathy, but the moment he relaxes
this effort will lapse into his former condition. As the disease
progresses the hebetude becomes more profound and is overcome with
greater difficulty. In mild cases it may continue until the occurrence
of convalescence, but in grave cases it is soon lost in delirium. This
is one of the commonest symptoms of the disease. If I should rely
solely upon my own experience, I should say that it was rare for any
but the mildest cases to run their course without its occurring at
some time or other. Louis found, however, that it was absent in 32
cases, 8 of which were fatal, out of 134 cases, and Murchison in 33
cases, 3 of which ended in death, out of 100 cases. In 8 of these
fatal cases death was due to perforation--a fact which would seem to
show, as suggested by James C. Wilson, that this symptom is not
dependent upon the intensity of the local disease alone. The delirium
of course varies with the severity of the other symptoms, and
especially with the intensity of the fever. In its mildest form it
consists of a slight confusion of ideas, which is readily dissipated
by fixing the patient's attention, and is most apt to occur in the
night or when he first wakes up from sleep. In other cases it is much
more marked; occasionally it is violent and noisy; the patient may
talk wildly and incoherently, he may break out into a paroxysm of
screaming, or, possessed with a sudden terror, he may leave his bed
and attempt to rush from the room or to jump from the window. Later in
the course of the disease the active delirium subsides, and low
muttering delirium takes its place. The latter may go on until
convalescence occurs, or the patient may gradually fall into a
comatose condition, which very often ends in death.

The delusions from which the patient suffers are various. I have known
in two instances a perfectly pure young girl call loudly for her baby,
which she accused her mother and sister of keeping from her. Very
frequently patients insist that they are in a strange place, and beg
piteously to be taken to their home and friends; occasionally, in
grave cases, the patient declares that there is nothing the matter
with him. This Louis was accustomed to regard as a bad symptom, having
never known recovery to take place after it. Delirium generally first
makes its appearance some time in the course of the second week, but
occasionally the invasion of the disease is marked by maniacal
excitement. I have known delirium to occur on the second or third day.
Louis records two cases in which it was present during the first
night, and Bristowe[51] one in which it was noted on the fourth night.
It is sometimes so prominent a symptom in the beginning of an attack
that the patient has at first been supposed to be affected with acute
mania. M. Motet[52] indeed refers to a case in which a man was
actually admitted into an insane asylum before the true nature of his
disease became known. On the other hand, delirium may not occur until
much later in the disease--sometimes not before the close of the third
or even the fourth week, when it may suddenly make its appearance when
least expected. I have known it to be present in a marked degree
during a relapse when it had been wholly wanting in the primary
attack.

[Footnote 51: _Trans. Path. Soc. Lond._, vol. xiii.]

[Footnote 52: _Archiv. gen. de Med._, 1868, quoted by Murchison.]

During convalescence, especially in cases in which there has been much
{279} mental disturbance during the febrile period, the intellect may
be weak, and continues so in some cases even after recovery in other
respects is complete; but it is rarely permanently impaired. Insanity
may also occur during the convalescence or after recovery, but it is
usually under these circumstances amenable to treatment. In some cases
the moral sense appears to be weakened after an attack, as in the case
reported by Nathan Smith, in which a young man of previously good
habits developed thieving propensities after his recovery.

Hyperaesthesia of the skin exists, according to Murchison, in about 5
per cent. of the cases, and may occur at any stage of the disease. It
is chiefly observed in the abdomen and lower extremities, and is more
frequently met with in women and children than in adult males. In a
case which was partially under my care during the past summer the
slightest touch made the patient, a boy of fifteen years, cry out with
pain, and the administration of an enema gave him excruciating agony.
Occasionally, the tenderness over the abdomen is so great that it is
sometimes difficult to distinguish it from that due to peritonitis,
except by the coexistence of hyperaesthesia in other parts of the
body. It is very often associated with spinal tenderness, and
sometimes with other spinal symptoms. Murchison does not regard it as
a formidable symptom.

Cutaneous anaesthesia may also occur, but it is certainly less common
in the earlier stages than hyperaesthesia. Rilliet and Barthez look
upon it as of grave diagnostic import when it occurs in children.

Muscular tremor is also a common symptom of typhoid fever. A little
tremulousness of the tongue when protruded may often be detected
before the close of the first week. A little later the hands will be
observed to tremble when held up, and still later twitching of the
tendons at the wrist may be appreciable while the pulse is being felt.
When muttering delirium supervenes this subsultus tendinum becomes
constant, and extends to other parts of the body. The hands of the
patient are frequently then in constant motion, either picking at the
bed-clothes--a very unfavorable symptom--or moving in an objectless
manner through the air. This condition presents many points of
resemblance to that often seen in delirium tremens, and is said to
come on earlier and to be more marked in those who are addicted to the
abuse of alcoholic liquors. Hiccough is occasionally observed toward
the close of grave cases, and is justly regarded as a bad symptom.

Spasmodic contraction of various groups of muscles is occasionally
observed in severe cases, but is less frequent than muscular tremor,
and in my experience is generally met with in the earliest period of
the disease. The muscles of the extremities, especially those of the
legs, are oftenest affected, but I have known the head as rigidly
retracted as in tubercular meningitis, and have seen cases in which
strabismus has been an early symptom. Murchison has had patients under
his care who have suffered from constriction of the pharynx to such an
extent that they could not swallow. He also reports cases in which
trismus and spasm of the glottis have been present. General
convulsions are not common, but occasionally do occur. Although a very
grave symptom, they are not invariably fatal. Recovery took place in
one of two cases which came under my own observation, and in four of
the six recorded by Murchison. They are not always associated with an
albuminous {280} condition of the urine. In neither of my cases was
there albuminuria, and in only one of the four of Murchison's cases in
which the urine was examined was it present. In one of my cases--the
fatal one--the convulsions seemed to have been induced by giving the
patient improper food; in the other no cause could be discovered.

Ringing or buzzing noises in the ears are present in the early stage
of the disease in a large proportion of the cases, and may sometimes
persist until the disease is well advanced. Usually, however, after a
few days they subside and give place to deafness. This is a very
common symptom, and may either affect both ears or be limited to one.
In the former case it is probably generally due to the blunted
perceptions of the patient, although in a few instances it may be
caused, as suggested by Trousseau, by inflammation of the Eustachian
tube. When only one ear is affected the deafness is of more serious
import, as it is then dependent upon the presence of local
inflammation, which may possibly extend to the meninges. It is, as a
rule, most marked in the severest cases. Unless there has been a local
inflammation it is not followed by permanent impairment of the
hearing. It has even been regarded by some observers as a favorable
symptom, but this opinion does not appear to rest upon a more
substantial basis than the observation of Louis, that the most
profound deafness adds nothing to the gravity of the prognosis.

Imperfect or perverted vision occasionally occurs in the course of
typhoid fever. In a case which was recently under my care, and which
has already been referred to in another connection, there was double
vision associated with strabismus. Sometimes haziness of vision, and
sometimes even visual illusions, are observed. Bartlett and Murchison
have often known intolerance of light present in cases characterized
by active febrile excitement. As a general rule, the pupils are widely
dilated and the conjunctiva pearly white--a condition which is in
marked contrast with what is seen in typhus fever. When, however,
stupor supervenes in bad cases, the pupils are frequently as much
contracted and the conjunctivae as much injected as in the latter
disease. In a few cases unequal dilatation of the pupils has been
noticed. Trousseau was accustomed in his clinical lectures to call
attention to the frequency with which sloughing of the cornea occurred
in the condition known as coma vigil, in which the patient lies with
his eyes wide open. He attributed this accident to the fact that the
eye in this condition is not kept constantly moist by the occasional
closure of the eyelids, and hence, as its innervation is also
impaired, is especially prone to take on ulcerative inflammation. In
other cases there is a free secretion of viscid matter, which often
glues the eyelids together.

The sense of taste is often lost or perverted. This is partly due to
impaired innervation of the tongue and palate, and partly to the thick
deposits which usually cover the mucous membrane of these organs.

Frequent observations of the temperature in typhoid fever not merely
give most important information in a diagnostic and prognostic point
of view, but also often furnish valuable indications for treatment.
From a close study of a large number of cases, Wunderlich and other
physicians have discovered that the pyrexia has certain characters
which distinguish it from other fevers, and which, being present in a
case in which the other symptoms are obscure or ill defined, will
often enable us to recognize {281} its true nature. The pyrexia may be
divided into three periods, each having its own peculiarities. It is
usually said that each period lasts about a week, but in severe cases
the second and third periods extend over a longer time than this, and
the occurrence of a complication or of any other disturbing influence
will have its effect in producing either a prolongation of any one or
more of these periods, and especially of the last two, or an unwonted
elevation or fall of temperature. During the first period there is a
progressive rise of temperature, but the rise is never so abrupt as in
typhus or in many of the phlegmasiae. As there are morning remissions,
ranging from a degree to two degrees in extent, corresponding to the
morning fall in the daily variations of temperature, the tracing upon
the temperature chart will be a zigzag line, each evening temperature
being from a degree and a half to two degrees higher than that of the
preceding evening, while the same difference will be observed in the
morning temperature. The temperature ought, therefore, never in an
uncomplicated case to be much over 100 degrees on the first evening or
102 degrees on the second. A temperature of 104 degrees at any time
during the first or second day will consequently exclude typhoid fever
from the diagnosis. From six to eight days are usually occupied before
the maximum is reached. I have seen it attained as early as the fourth
day in mild cases, and, on the other hand, not until much later in
severe ones. It is usually 104 degrees or 105 degrees, but will of
course vary with the gravity of the other symptoms. The temperature
rarely rises higher than 106 degrees at this period. On the other
hand, I have known cases in which it never exceeded 103 degrees during
their whole course. It would therefore be wrong to exclude typhoid
fever from the diagnosis, as Wunderlich does, if this temperature is
not reached by the sixth, or at latest the eighth, day.

[Illustration: FIG. 12. Chart of typical range of temperature in
typhoid fever, after Wunderlich.]

In the next period the temperature usually ceases to rise, but has a
tendency to oscillate about the maximum temperature of the previous
period as a fixed point, occasionally not quite reaching it, at other
times rising a little above it. The morning remissions, too, become
less decided. In other words, the fever now becomes continuous. This
period, although usually lasting about a week, may extend over more
than two weeks, even in the absence of complications, in cases which
run a severe course, and when it is prolonged from this cause the
temperature may again show a tendency to rise, and may even attain an
elevation considerably above that of the preceding period. The
prognosis in all such cases in which the temperature rises after the
middle of the second week is grave. Temperatures of 108 degrees, and
even of 110.3 degrees, have been noted at this time. Death invariably
follows such high temperatures as these, but before death actually
occurs a considerable fall of temperature very often takes place.
Wunderlich has also called attention to the fact that it is not
uncommon for a sudden and temporary remission of temperature to take
place at this stage, varying from one degree to two degrees and a
half, which may last from ten to twelve hours, and which usually has
occurred in his experience from the sixteenth to the eighteenth day.
Toward the close of the second period the morning remissions will be
observed to be more decided, while the evening temperature remains
about the same as before. The beginning of the third period is
indicated by a diminution of the evening exacerbation, while the
morning remissions become still more marked. The diminution is
progressive, but slow, the {282} temperature each evening falling
short by from half a degree to a degree of the point it reached the
preceding evening. The morning remissions, on the other hand, each day
become greater, a fall of three and a half degrees being not uncommon.
The lysis, therefore, occupies usually a longer time than was required
by the pyrexia in reaching its maximum. Toward the close of this
period the morning temperatures may be normal, as even subnormal,
while an elevation of temperature may continue to take place in the
evening. Occasionally, however, an abrupt defervescence takes place.
The duration of this period will be very much prolonged if
complications are present or if the intestinal ulcers are slow in
healing. I have known it to last for more than three weeks. During
convalescence the temperature is frequently subnormal even in the
evening, but the slightest cause is often sufficient to produce a
considerable though temporary elevation of temperature. I have known
the temperature in one case to rise from 99 degrees F. to 105.6
degrees in a few hours in consequence of an indiscretion in diet, and
in another from 100 degrees to 104 degrees from the suffering and
excitement caused by a severe attack of toothache. Indiscretions in
diet are a fruitful source of these recrudescences of fever. The fever
of the third period has all the characters of an irritative fever, and
is probably kept up by the irritation arising from the intestinal
ulcers. On the other hand, that of the first two periods is due to the
action of the specific poison upon the nervous system and the other
tissues of the body, and corresponds exactly with the primary fever of
the eruptive diseases.

{283} [Illustration: FIG. 13. Chart showing recrudescence of fever
from indiscretion of diet.]

The febrile movement, however, rarely follows a perfectly typical
course, and I consequently find, in looking over the temperature
sheets of a large number of cases, very few which bear, except during
the first period, anything more than a general resemblance to the
chart which {284} Wunderlich has prepared as typical. A very slight
cause will exercise, as has already been said, a disturbing influence
upon the course of the fever, and serious complications or accidents
will of course produce a still more marked effect. An intestinal
hemorrhage, for example, will cause a rapid and decided fall of
temperature. I have often known it to fall from 104 degrees to the
normal temperature, or even below it. This depression, unless the
bleeding continues and the case ends fatally in the course of a few
hours, is only temporary, the temperature rising within twenty-four
hours to its former height, and sometimes even beyond it. A free
epistaxis or a copious diarrhoea will in the same way cause a fall of
the temperature, but it is rarely so marked as in the preceding case.
The same effect is produced by the administration of large doses of
quinia or by the application of cold water either in the form of the
bath, the douche, or any other form, to the surface of the body. On
the other hand, the occurrence of a complication will cause a rise of
temperature, often considerably above the maximum of the first period.

[Illustration: FIG. 14. Chart showing fall from intestinal
hemorrhage.]

The thermometer should be used at least twice daily. In this country
it is generally introduced into the axilla, and less frequently into
the mouth, for the purpose of making an observation. In other
countries it is not infrequently inserted into the rectum, and even
into the vagina. The best hours for making the thermometric
observations are eight in the morning and eight in the evening, since
it has been ascertained from {285} frequent observations that the
daily remissions are more marked between the hours of 6 and 8 A.M.,
and that the temperature usually reaches its maximum some time between
those of 7 and 12 P.M.

Loss of appetite is, except in mild cases, one of the earliest
symptoms of the disease, and usually persists as long as the fever
lasts. It is sometimes accompanied by positive loathing for food, but
generally there is no great difficulty in persuading the patient to
take the necessary amount of nourishment. During convalescence the
appetite returns, and is occasionally immoderate, so that it is
frequently necessary to curb it lest harm should be done by over
indulgence.

Thirst, usually proportionate to the degree of fever, is also present
in the beginning of the fever. Later, when the patient sinks into a
semi-unconscious condition and becomes insensible to the wants of the
system, he will cease to call for water, although it is still urgently
needed.

Nausea and vomiting sometimes occur at the beginning of the disease,
but they have not been such frequent symptoms in my experience as they
would appear to have been in that of Murchison, who says that they are
of such common occurrence that the patient is often supposed at first
to be suffering merely from a bilious attack. He does not regard them,
when occurring at this stage, as serious symptoms. Indeed, he
expresses the belief that the subsequent course of the disease is
sometimes favorably modified by them. They may also occur later in the
disease, and are then of grave import, as they are not infrequently
the consequence of peritonitis. Louis regarded vomiting as a grave
symptom, but it is probable it occurred in the cases from which he
makes his deductions late in the course of the disease. It may
sometimes occur during convalescence, and may then interfere very
materially with the proper nutrition of the patient. The matter
vomited usually consists of a greenish bilious fluid, with the food
last taken. In some cases blood has been thrown up.

The tongue at the beginning of an attack of typhoid fever is usually
moist and coated with a thin white fur, and in mild cases may retain
these characters until the close. Even in some cases which terminate
fatally in the course of the second week, the tongue, with the
exception of being less moist than in health, may present no marked
deviation from this appearance. Generally, however, as the disease
progresses, and sometimes as early as the tenth day, it becomes dry
and brownish, and is protruded with a tremulous motion. Still later it
tends to cover itself with a thick brown coating. This coating is
disposed principally along the middle of the organ, leaving uncovered
the edges and tip, which are very apt to be unnaturally red in color.
The bare portion at the tip is often rudely triangular in shape--a
point which is regarded as of some importance in the diagnosis of the
disease by Da Costa. In bad cases, during the course of the third week
the tongue is frequently crossed by cracks and fissures, which are the
cause of much discomfort to the patient, and when deep may bleed and
leave behind them scars which are recognizable during the remainder of
his life. In other cases the tongue is dry, brown, and shrivelled, or
covered with a tenacious, viscid secretion which renders it difficult
to protrude it.

In favorable cases, as convalescence approaches the tongue regains by
degrees its normal appearance. At first the only noticeable change may
{286} be that the organ is a little less dry than before. In a few
days it will be observed to have become moist and to be gradually
throwing off its coating. The process is, however, a slow one, and
one, moreover, subject to frequent interruption. Very often, when it
seems nearly completed it will be suddenly arrested, and the tongue
become dry and brown. Sometimes, instead of cleaning itself gradually,
the tongue throws off its coating in large flakes, leaving the mucous
membrane red and shining, as if deprived of its papillary structure.
Wood was accustomed to teach that if the tongue when thus cleaned
remained moist convalescence might be expected, but would always be
tedious. This is an observation the correctness of which I have had
abundant opportunity to confirm. If anything happens, however, to
interfere with the progress of convalescence, it not infrequently
becomes dry and coats itself over again. When the restoration to
health is retarded by the continuance of diarrhoea or by the
occurrence of any intercurrent affection, the tongue will often become
pale and flabby and be the seat of superficial ulcerations or of
aphthous exudations.

The mucous membrane of the posterior fauces is also often red and dry
and covered with a glutinous secretion, which often materially
interferes with swallowing. The lips and teeth are in bad cases
encrusted with sordes, and the former are dry and cracked, and bleed
readily when picked.

Meteorism or tympanites is observed in the greater number of cases of
typhoid fever, having been noted by Murchison in 79 out of 100 cases,
and by Hale in 130 out of 179 cases, and in only 43 of the remainder
of his cases is it expressly stated to have been absent. My own
experience leads me to believe that it is present in even a larger
proportion of cases; in fact, that it is rarely absent. It is, as a
rule, later in making its appearance than the other abdominal
symptoms, showing itself usually about the end of the first or the
beginning of the second week. It is generally most marked in grave
cases, especially those attended by severe diarrhoea, but I have seen
it highly developed in cases in which the symptom was not present at
all or but little developed. It may vary, moreover, frequently in
degree at different times in the same case, but when once present
generally persists until convalescence is established or death occurs.
When extreme, it may give rise to distressing dyspnoea by preventing
the descent of the diaphragm.

The meteorism is usually preceded and accompanied by gurgling and
tenderness on pressure in the right iliac fossa. The former of these
symptoms is most marked in cases in which diarrhoea exists, and is
caused by the presence of liquid and gas in the lower part of the
ileum. The tenderness is unquestionably due to the presence of ulcers
in the same part of the bowel. There is also occasionally pain in the
region of the umbilicus, but this is a much less frequent symptom.

Enlargement of the spleen was noted by Hale as being present in some
of the cases which he has described. It is a frequent symptom of the
disease, and may be generally demonstrated by percussion in the course
of the second week. It has not, however, often happened to me to be
able to feel the organ enlarged through the abdominal walls, as
Murchison asserts he has been able to do. Indeed, tympanites is
usually present in a sufficient degree to render this difficult. The
enlargement {287} occurs more frequently in persons under thirty years
of age than in those over it.

Diarrhoea is one of the most frequent symptoms of the disease,
especially in severe cases, and there are very few mild cases in which
it does not occur at some period of their course. Louis noted it in
all but three of his fatal cases, Murchison in 93 out of 100, and M.
Barth in 96 out of 101. It varies in different cases in severity, in
duration, and in the time at which it appears. It may be one of the
earliest symptoms, presenting itself frequently on the first day, and
often being the only one which occasions uneasiness to the patient or
his physician. At other times its appearance may be postponed until
the end of the first week, or even until the patient is apparently
entering on convalescence. It may be mild in the beginning and become
more severe as the disease progresses, or after having been at first
acute may cease spontaneously in a few days to occasion any
uneasiness. In degree it may vary from two stools to three or four, or
even twenty, in the course of the twenty-four hours. It is absent in a
few cases, but in many even of these cases the bowels will be found to
act inordinately after a very moderate dose of purgative medicine. I
have known, for instance, the administration of a single teaspoonful
of castor oil to be followed by five or six stools in an adult.
Constipation does, however, actually exist in a certain number of
cases. Murchison has known the bowels in cases in which a relapse has
occurred to be constipated in the primary attack and relaxed in the
relapse. There is no relation between the severity of the diarrhoea
and the extent of the local lesion. Although oftenest met with in mild
cases, constipation has existed in cases in which perforation of the
bowel or intestinal hemorrhage has occurred during life, or very
extensive lesions been found after death.

The stools are fetid and ammoniacal, and are alkaline in reaction,
instead of acid as in health. They are usually liquid and of the color
of yellow ochre. Murchison says that they separate, on standing, into
two layers--a supernatant fluid and a flaky sediment--but that,
occasionally, instead of being watery they are pultaceous, frothy, and
fermenting, and so light as to float in water. I have myself often
seen the appearance which Bartlett compares to that of new cider. They
may contain blood, and when they do, occasionally present the
appearance of coffee-grounds. They are not infrequently, in grave
cases, passed involuntarily.

Intestinal hemorrhage is fortunately not a frequent symptom of typhoid
fever. It may occur as early as the fifth or sixth day, but is more
common after the middle of the second week or in the third or fourth
week. In 60 cases observed by Murchison in which the hemorrhage
exceeded six ounces it began during the second week (mostly toward its
close) in 8; during the third week in 28; during the fourth in 17;
during the fifth in 1; during the sixth in 3; during the seventh in 1;
and during the eighth week in 1; while in one case the date of its
occurrence is not noted. In the cases observed by Liebermeister and
Griesinger, 113 in all, the bleeding took place in a much larger
proportion of cases at an early period of the disease, occurring in as
many as 43 in the second week, and in only 27 during the third. In 7
cases in which I had the opportunity of observing it in patients under
my own care it occurred on the seventeenth day in 1; on the
twenty-third day in 1; during the {288} third week in 2; during the
fifth week in 2; and on the fifth day of a relapse in 1. There may be
a single hemorrhage, or the bleeding may be repeated one or more
times. In 5 of my cases there was a second hemorrhage, and in 2 of
them a third; and in several of Murchison's cases it recurred at
varying intervals after its first appearance.

When the bleeding occurs early in the disease it is usually
insignificant in amount, and is due either to extreme congestion of
the mucous membrane of the intestine, giving rise to rupture of the
capillaries, or to disintegration of the blood, allowing its ready
passage through the walls of the vessels. In the latter case it
usually coexists with petechiae or a hemorrhage from some other part
of the body, as, for instance, epistaxis or hematuria. After the
middle of the second week the hemorrhage is generally the result of
the laying open of a small artery, either by the detachment of a
slough from one of the glands of Peyer or by the involvement of its
walls in the ulcerative process. It is then often profuse, and may
even reach several pints in quantity. Murchison has, however, seen
profuse hemorrhage at such an early stage of the disease that it was
impossible that ulceration could have taken place. The blood is not
always voided immediately after a hemorrhage has taken place; it may
be retained for some days. Indeed, if the amount be large the patient
may die within a few hours of its occurrence without any appearance of
blood externally. This is, however, rare; it is more usual for the
hemorrhage to be repeated before death takes place, but the occurrence
of the bleeding may be suspected in such cases by the abrupt fall of
temperature, sometimes below the normal standard, and by the extreme
prostration and pallor which come on suddenly without other assignable
cause. The depression of the temperature does not continue long. It
generally reaches its former elevation, or even exceeds it, in the
course of twenty-four hours.

There would appear to be a slight difference in the frequency with
which intestinal hemorrhage occurs in different times and at different
places. Murchison noted it in 58 cases of 1564, or 3.77 per cent.;
Louis in 8 cases of 134, or 5.9 per cent.; Liebermeister in 127 cases
of 1743, or 7.3 per cent.; Griesinger in 32 cases of 600, or 5.3 per
cent.; and I have noted it 7 times in 81 cases, or in about 8.5 per
cent. Liebermeister makes it twice as frequent in women as in men. It
seems to be much less common in children than in adults, for in 252
patients under fifteen years of age observed by Taupin, Rilliet, and
Barthez it occurred in 1 only. There is considerable diversity of
opinion among observers in regard to the importance of this symptom.
Murchison lost 32 of his 60 cases. In 11 of the 32 fatal cases the
immediate cause of death was peritonitis; in 14 of the remaining 21
cases the patients died within three days of the bleeding, and in 8 of
the 14 within a few hours. Of Liebermeister's 127 cases 49, and of
Griesinger's 32 cases 10, terminated fatally; 3 of my own cases ended
in death, but none of them until several days had elapsed after the
bleeding. In the face of facts such as these there have not been
wanting authors to assert that the effect of the hemorrhage was
sometimes beneficial. Chief among these are the celebrated Irish
physician Graves and his devoted admirer Trousseau. There may
occasionally be a slight subsidence of the nervous symptoms upon the
occurrence of a hemorrhage, consequent upon the reduction of
temperature {289} which usually accompanies it, but this relief is
only temporary, and procured at too great expense to be really of
service to the patient.

The bleeding is most frequently observed in bad cases. All the cases
which were under my care in which it occurred were of great severity
from the very start. In 18 of Murchison's 60 cases the antecedent
symptoms were mild. In 3 of my cases there was severe diarrhoea. In 2
of the other cases, 1 of which was fatal, the bowels were constipated,
and in another one, also fatal, they were slightly loose. In 8 of
Murchison's cases, 6 of which were fatal, the bowels had been
constipated up to the time of its occurrence. The blood, if voided
immediately after its escape into the intestines, is generally fluid
and bright red in color. When retained for a day or two it is passed
in dark clots, and if retained longer than this it is usually mixed
with fecal matter when discharged from the bowels, and gives the
stools a tarry appearance and consistence, which is not always
recognized by inexperienced attendants as due to blood.

It has been asserted that intestinal hemorrhage has become more
frequent since the introduction of the cold-water treatment, but
Liebermeister shows this to be an error, for he has found that of 861
cases treated before the introduction of this treatment, 72, or 8.4
per cent., had intestinal hemorrhage, but that of 882 cases treated
since its introduction hemorrhage occurred in 55, or in 6.2 per cent.
Other methods of treatment have also been charged with inducing a
tendency to hemorrhage, but probably not upon more substantial grounds
than the above.

The occurrence of perforation may be suspected when the patient is
suddenly seized with acute pain in the abdomen, accompanied by
symptoms of collapse and occasionally by rigors. The fall of
temperature is often considerable. Liebermeister refers to one case in
which it was as much as 5-1/2 degrees, or from 104 degrees to 98-1/2
degrees. Very soon the abdomen becomes tender on pressure, and, if it
were not so before, hard and tympanitic; the pulse grows frequent,
small, and sometimes almost imperceptible; the breathing is thoracic;
the physiognomy expresses great suffering; the features are
contracted, and the face is bathed in profuse perspiration. Nausea and
vomiting come on soon after inflammation has commenced, and rapidly
exhaust the patient. The decubitus is dorsal, and the legs are
generally drawn up so as to relax the abdominal muscles. Prostration
rapidly increases until death puts an end to the patient's sufferings.
Occasionally, the symptoms are more obscure. Pain and rigors may both
be wanting, and nothing but the extreme prostration, the frequent and
feeble pulse, and the distended condition of the abdomen will indicate
the gravity of the danger. This is not infrequently the case in
delirious patients. Death may take place during the collapse, but this
is rare. It more frequently takes place on the second or third day; on
the other hand, it may be postponed until much later. Liebermeister
and Murchison refer to cases in which there was an interval of two or
three weeks between the first symptom of perforation and the fatal
result.

Perforation of the intestine was formerly regarded as an inevitably
fatal accident, but this view is no longer entertained. I have had
under my observation cases in which all the symptoms of this accident
were present, and in which recovery took place. In some of these cases
there {290} may have been an error of diagnosis, but all of them will
not admit of this explanation. Moreover, cases of a similar character
have been reported by physicians whose skill in diagnosis is
universally recognized. Thus, Murchison reports six such cases,
Tweedie two, and Wood one. Liebermeister and Bristowe[53] also both
say that recovery is possible. This view is sustained by the results
of certain autopsies. In one of these, reported by Buhl,[54] a
perforation was found completely closed by adhesions to the mesentery,
and in others reported by Murchison partial adhesion had taken place
between the edges of the perforation and the abdominal walls or to an
adjoining coil of intestine. Occasionally, the inflammation excited by
the perforation may be circumscribed and terminate in an abscess,
which may permit recovery by discharging itself into the bowel or
externally. At other times, however, it ruptures into the peritoneal
cavity, when death speedily ensues.

[Footnote 53: _Transactions of the Pathological Society of London_,
vol. xi. p. 115.]

[Footnote 54: Cited by Murchison.]

Perforation is, fortunately, not a frequent accident in typhoid fever.
It was the cause of death in 20 only of 250 fatal cases collected by
Hoffmann. It occurred, according to Liebermeister, in only 26 cases, 3
of which ended in recovery, in more than 2000 cases observed at the
hospital at Basle. Murchison observed it 48 times in 1580 cases,
Griesinger 14 times in 118 cases, and Flint twice in 73 cases.
Murchison found that in a total of 1721 autopsies, the details of
which were collected from various sources, it was the cause of death
in 196, or 11.38 per cent. It would appear to be rather more common on
the continent of Europe than in England or in this country.
Perforation is much more frequently met with in men than in women. The
patients were men in 15 of 21 of Liebermeister's cases, in 51 of 73 of
Murchison's, and in 72 of 106 cases collected by Nacke. It is rarer in
children than in adults. Rilliet, Barthez, and Taupin met with it only
three times in 232 children under treatment. Murchison has, however,
had a fatal case in a child of five years of age. It is also not
common after forty years of age, but does occasionally occur, although
the contrary has been asserted.

Perforation is most likely to happen during or after the third week of
the disease, but it has been met with as early as the eighth day, as
in a case reported by Peacock. On the other hand, in three cases cited
by Morin[55] it did not occur until the seventy-second, seventy-sixth,
and one hundred and tenth day, respectively. Instances are on record
in which it has taken place after the patient was supposed to be
thoroughly convalescent and had returned to his occupation. When it
occurs early it is due to the separation of a slough. After the middle
or end of the third week it is probably always the result of the
extension of the ulcerative process to the peritoneal coat. In a large
proportion of cases the perforation has been preceded by symptoms of
great gravity, such as severe diarrhoea, great tympany and tenderness
of the abdomen, and intestinal hemorrhage, but in a certain number of
instances the cases in which it has occurred have been of a mild
character, the patient in many of them not considering himself sick
enough to take to his bed or even to abstain from his daily labor.
After death the perforating ulcer has been found to be the only one.

[Footnote 55: Quoted by Murchison.]

The most frequent causes of perforation are the irritation arising
from {291} indigestible and unsuitable food, distension of the bowels
by feces or gas, vomiting, and movements on the part of the patient.
Liebermeister calls attention to the frequency with which ascarides
are found in the intestines of those who die of perforation, and is
inclined to think they may have something to do with causing it.
Morin[56] reports a case in which the perforation appeared to be
caused by the administration of an enema.

[Footnote 56: Quoted by Murchison.]

For our knowledge of the changes in the composition of the urine we
are largely indebted to Parkes and certain German observers. As the
disease generally begins insidiously, the condition of the urine
before the attack and during the first two or three days has not been
ascertained with certainty. During the latter part of the first week
the amount of water is greatly diminished, occasionally falling to
one-fourth or one-sixth of the usual quantity. In the second and third
weeks it increases, and at the end of the fourth week may again be
normal. The amount may, however, vary from day to day, but its
variations do not stand in close relation to those of the febrile
heat; that is, the thermometer may mark one day 104 degrees, and the
next day 100 degrees, while the amount of urine remains the same.
Still, when the temperature begins to fall permanently it increases at
once, or, according to Thierfelder, two or three days after. The
specific gravity is usually high in almost all cases in which the
urine is scanty, and may be as high 1038. With the establishment of
convalescence the specific gravity often diminishes before the water
begins to increase. In other words, the lessening of the solids of the
urine frequently takes place prior to the increase of the water.

The reaction of the urine is very acid in the beginning, but the
acidity is not due to an increased secretion of acid, but simply to
concentration. Later it may become alkaline, and even ammoniacal. The
color of the urine is darker than in health during the early part of
the febrile period. This is due partly to concentration, and partly to
increased disintegration of the blood-corpuscles, which is a
consequence of the fever.

The quantity of urea is augmented during the fever, and especially
during the first week, when the water and chlorides of sodium are most
diminished. As a general rule, the higher the temperature the greater
the amount of urea. It may, however, be very much diminished during
the presence of inflammatory complications. On the other hand, it is
not affected by diarrhoea. Uric acid is uniformly increased, the
amount of increase being relatively greater than that of the urea; it
is often doubled, and sometimes the increase is even more than this.
This increase takes place, according to Zimmer, up to the fourteenth
day. It diminishes after this, and during convalescence may fall below
the normal amount. Copious deposits of urates may occur at any time in
the course of the disease. The chloride of sodium is usually
diminished in amount. This diminution is partly due to a less amount
of this salt being taken with the food, and partly to the fact that
large quantities of it pass away with the stools. As the diminution
cannot always be fully accounted for in this way, it would appear that
it is also stored up in the body during the fever. In cases in which
sweating and purging are absent the sulphuric acid is increased in
amount. The phosphoric acid is at first slightly diminished, but later
undergoes an increase. The hippuric acid is also diminished.

{292} Parkes found albumen in the urine in 7 out of 21 cases. In 5 of
these it was temporary, and entirely disappeared before the patients
left the hospital. Becquerel found it in 8 out of 38 cases, Andral in
only 4 out of 34 cases. Griesinger found it commonly, though it was
usually temporary. He met with only four or five cases in which it was
never present. Kerchensteiner found albumen in a fourth part of the
severe cases. Brattler noticed it in 9 out of 23 cases. I have very
frequently found it myself, but it has always been in my cases a
temporary phenomenon. Desquamative nephritis may occur occasionally in
the course of typhoid fever, and give rise to the appearance of a
large amount of albumen in the urine, and also occasionally of blood.
Renal epithelia and casts are sometimes seen in cases in which there
is albuminuria, but usually soon disappear. Zimmermann asserts that in
all but very slight cases casts may be found even when no albumen can
be detected. The statement is probably too general, but there is no
doubt of the occasional presence of casts under these circumstances.
Bladder epithelia and pus-cells are seen in a few cases in small
quantities, but decided cystitis is rare, unless it has ensued upon
retention of urine. Sugar has not been found except in the urine of
diabetic patients, who may have happened to contract typhoid fever. In
these patients the sugar diminishes, and is sometimes wholly absent
during the continuance of the fever. Leucin and tyrosin have been
found by Frerichs, but at present no observations have been made as to
the frequency or import of their occurrence.

In many cases, when the prostration is extreme, the urine is passed
involuntarily, but in some of these cases the incontinence of the
urine is only apparent, and is really the result of over-distension of
the bladder. This is a condition which is very apt to be overlooked,
and I have known paralysis of the bladder to result in consequence of
this neglect, and to continue sometimes after convalescence has been
established.

COMPLICATIONS AND SEQUELAE.--Although cerebral symptoms are among the
commonest manifestations of the disturbing effects produced in the
economy by the typhoid fever poison, they are almost always
independent of inflammation of the brain and its membranes. In a few
cases, however, the lesions of meningitis have been found after death.
In some of these it has come on without assignable cause, in others it
has been the consequence of pyaemia, of tubercles, or of the extension
of inflammation from the petrous portion of the temporal bone.
Occasionally, during convalescence, some impairment of the intellect
is observed. This may consist in simply some loss of memory or
childishness of manner. At other times delusions of a mild form are
present, or else the patient is liable to attacks of acute mania,
sometimes violent, coming on suddenly and without fever. In a few
instances the moral sense seems to have been perverted, as in the case
reported by Dr. Nathan Smith, already referred to, in which a young
man of previously good character developed a propensity to steal after
his attack. Recovery with the re-establishment of the physical health
almost occurs in these cases. Murchison says he knows of no case in
which this condition has been permanent. On the other hand, Dr. C. M.
Campbell,[57] who had the opportunity of observing an attack of
typhoid fever among some insane patients {293} at the Durham County
Asylum, reports that the mental state was in no case injuriously
affected by the disease, but, on the contrary, underwent a marked
improvement in several of the cases. Indeed, in two of the cases, in
which the prognosis had become very unfavorable, mental recovery began
during the attack of fever.

[Footnote 57: _The Journal of Mental Science_, July, 1882.]

Paralysis, muscular tremors, and chorea are also occasionally observed
after attacks of typhoid fever. According to Murchison, paralysis does
not supervene until several weeks after the commencement of
convalescence. It may last for several weeks or months, but recovery
in the majority of instances eventually takes place. According to
Nothnagel,[58] the most common form is paraplegia, but it may also
take the form of hemiplegia, strabismus, paralysis of the portio dura,
motor paralysis of individual spinal nerves, such as the ulnar or
peroneal, or local anaesthesia. On the other hand, neuralgias and
disturbances of sensation are not common sequelae of typhoid fever.

[Footnote 58: Cited by Murchison. See also article by Paget, _St.
Bartholomew's Hospital Report_, vol. xii.]

Degeneration of the muscular tissue of the heart is probably present
in some degree in every case of typhoid fever, being, of course, most
marked in the severest cases. There would seem, however, to be no
special tendency to disease of its valves or membranes. Arterial
thrombosis or embolism, giving rise to gangrene of the part supplied
by the obstructed artery, is of occasional occurrence. Patry,[59]
Hayem,[60] Trousseau,[61] and others report or refer to several cases
in which gangrene of the leg, hand, or cheek was observed, and among
others a case in which sphacelus depending upon obstruction of the
carotid artery, the result, as Patry thought, of arteritis, commenced
in the left ear, and extended from there to the forehead and
cheek.[62] A. Martin[63] reports the case of a woman who expelled from
the vagina a fetid-smelling structure of cylindrical form, which
proved to be the cervix of the uterus, with the upper part of the
vagina, and in whom menstruation was not re-established until after
the performance of an operation. Spillmann[64] has also called
attention to the occurrence of gangrene of the vagina and vulva in
cases of typhoid fever. {294} This complication is generally met with
toward the end of the febrile period.

[Footnote 59: _Archives generales de Medicine_, 1863, vol. i. pp.
129-549.]

[Footnote 60: _Loc. cit._]

[Footnote 61: _Clinique medicale_.]

[Footnote 62: Since the above was written Barie has called attention
in the _Revue de Medicine_, Jan. and Feb., 1884, to the frequency with
which acute inflammation of the arteries occurs as a sequel of typhoid
fever. The author, whose investigations were limited to the larger
arteries, found that the vessels generally implicated are in the order
of their frequency, the posterior tibial, the femoral, and the dorsal
artery of the foot. The affection is usually unilateral, appears
during convalescence or when the patient leaves his bed, and occurs
just as often after light as after severe cases. He distinguishes two
varieties: 1, acute obliterating arteritis, and, 2, acute parietal
arteritis. The first variety is characterized by embryonal
infiltration of all the tissues, by disappearance of the smoothness of
the intima, which becomes uneven and granular, and by the formation of
a secondary thrombus, and almost invariably terminates in dry
gangrene. The second is merely an inflammation without such a clot,
and always terminates in recovery without gangrene.

The symptoms of obliterating arteritis are--pain, more or less sudden
in its onset, directly over the course of affected vessels, and
increased by pressure, by the erect position, and by walking;
diminution, and then absence, of pulsation; swelling of the limb,
without oedema or redness; and, later, the appearance of bluish
mottling of the surface, and, more rarely, of patches of purpura;
lowering of the temperature, with or without troubles of sensibility,
such as formication, anaesthesia, etc., and the appearance of a hard
and painful cord, due to the formation of the thrombus. In the
parietal form the diminution of the pulsations is sometimes preceded
by a considerable exaggeration of their amplitude, and, while the
temperature on the affected side is usually lowered, it may sometimes
be increased.]

[Footnote 63: _Centralblatt f. Gynakol_, 1881.]

[Footnote 64: _Archives generale_, Mars, 1881.]

Venous thrombosis, the result of weakness of the heart's action, is
more frequently observed. It occurs generally during the convalescence
of cases which have run a severe course, and usually affects the veins
of the lower extremities. I have seen both the femoral veins
obstructed from this cause at the same time. All the cases which have
come under my own observation have ended in recovery, and only 2 of 31
collected by Liebermeister terminated fatally. Death occurred in 3 of
the 17 cases collected by Murchison, but in none of them was this
result attributable to this complication alone. There is, however,
always danger of a portion of the thrombus becoming detached and
producing embolism of the pulmonary artery.

Pyaemia is said by Murchison and other authors to be an occasional
complication, but it is certainly rare in this country. In the milder
cases abscesses form during convalescence beneath the skin in
different parts of the body. In the more severe cases pus is deposited
in the joints or in the internal organs. Albert Robin[65] has reported
two cases in which there was suppurative joint affection. In one of
these the joints of the fingers and toes, with the sheaths of the
corresponding extensor tendons and both knee-joints and one
shoulder-joint, were affected. In the other the left knee was filled
with pus. In both cases the fever soon assumed an adynamic character.

[Footnote 65: _Gazette de Paris_, 1881.]

Laryngitis may sometimes occur in the course of typhoid fever, and
when it assumes the diphtheritic form and runs on to the formation of
ulcers is a very serious complication of typhoid fever, as it is not
infrequently accompanied by oedema of the glottis and gives rise to
the necessity for tracheotomy. It is fortunately, at least in its
worst forms, rare in this country. In Germany, judging from the number
of cases collected by Hoffmann and Griesinger, it is of more common
occurrence. The ulcers are oftener met with in some epidemics than in
others. During the winter of 1860-61, which I passed in Vienna, the
frequency with which they occurred was the subject of remark among
those who were in attendance upon the various clinics.

I have already called attention to the frequency with which bronchitis
in some form or other attends upon typhoid fever. When it invades the
smaller bronchial tubes it occasionally gives rise to lobular
pneumonia or to collapse of some of the lobules of the lung. Lobar
pneumonia may also occur in the course of typhoid fever. It was
observed 52 times in 1420 cases of typhoid fever under treatment at
the Basle hospital from 1865-68. When it comes on late in the disease,
especially if the patient is comatose, or even semi-conscious, it may
be entirely overlooked, unless the lungs are carefully examined, as it
often does not reveal itself to us by any of the ordinary symptoms. It
may, however, occur early, and I have known it so prominent in the
beginning of an attack that the existence of typhoid fever was not
suspected. It sometimes terminates in abscess or gangrene, but is more
usually followed by chronic pneumonia, which may eventually either end
in recovery or lay the foundation for phthisis. Pleurisy with effusion
is also not an uncommon complication. It was observed, according to
Liebermeister, at the hospital at Basle 64 {295} times in 1743 cases
of fever. It is also a serious complication, as 21 of the 64 cases
terminated fatally. Murchison refers to three cases in which it was
followed by empyema. Other morbid conditions of the respiratory organs
which may occur as complications of typhoid fever are oedema,
infarction, hypostatic congestion of the lungs, emphysema, and
pneumothorax. Acute miliary tuberculosis is also an occasional
complication, but is oftener met with as a sequel. According to
Liebermeister, the tendency to pulmonary complications has diminished
since the introduction of the cold-water treatment.

Catarrhal or diphtheritic inflammation of the fauces and pharynx
occurs in a large number of cases, and frequently gives rise to a
great deal of difficulty in swallowing. Indeed, it has been so
frequently observed in some epidemics that a few writers have regarded
it as a symptom rather than a complication of the disease. Either of
the varieties of inflammation may extend through the Eustachian tube
to the middle ear and be the cause of deafness, which usually passes
off as the inflammation subsides. Occasionally, however, the affection
of the middle ear gives rise to perforation of the tympanum or to
caries of the petrous portion of the temporal bone.

Murchison says he has known the symptoms of and lesions of dysentery
to coexist with those of typhoid fever in several cases, and
Liebermeister asserts that diphtheria of the intestinal mucous
membrane is an occasional sequel to severe cases, especially when
other mucous membranes are the seat of diphtheritic inflammation. In a
few instances which have come under his observation it had given rise
to perforation of the bowel or to gangrene of the intestinal mucous
membrane.

Jaundice occasionally occurs in the course of the disease. I have
never happened to see this complication, and am inclined to think it
is rare in this country. Liebermeister, however, met with it 6 times
in 1420 cases, and Griesinger 10 times in 600 cases. Hoffmann found it
in 10 of 250 fatal cases, and Murchison was able to collect 9 cases,
all of which but one terminated in death. Several of Griesinger's
cases, however, ended in recovery. In a few cases the jaundice may be
attributed to catarrh of the biliary ducts, but this solution of the
question will not explain those cases in which the feces remain
colored throughout. In fatal cases marked degeneration of the liver
has been found, which Liebermeister regards as of similar character to
that which occurs in acute yellow atrophy. In two of Murchison's cases
the liver was small and its secreting cells loaded with oil. In most
cases it does not appear until late in the disease, but it has been
observed as early as the fifth day.

Abscess of the liver and diphtheritic inflammation of the mucous
membrane of the gall-bladder are among the rarer sequelae of typhoid
fever.

Peritonitis is the most serious of all the complications of typhoid
fever. Its most common cause is perforation of the bowel, but it may
also be due to the extension of inflammation to the peritoneal
membrane without ulceration. Liebermeister believes that it is
sometimes the result of the typhoid infiltration so frequent in
various tissues of the body taking place in the serous membrane. In
other cases it arises from the rupture of softened mesenteric glands,
of softened {296} infarctions in the spleen, or of the abscesses which
are sometimes the consequence of the circumscribed inflammation by
which perforation is occasionally prevented from proving immediately
fatal. Less frequent causes of it are rupture of the gall-bladder,
with the escape of gall-stones into the cavity of the abdomen,
abscesses of the ovary, and abscesses in the walls of the urinary
bladder. It is said by Murchison to have been in one case the result
of a pseudo-abscess in the sheath of the rectus muscle bursting
inward.

Swelling of the parotid gland occasionally occurs in typhoid fever,
but is much less common than in typhus. It is most frequently met with
in bad cases about the end of the third week or later, and generally
involves one side only. The swelling is hard and firm in the
beginning, and may terminate in resolution or suppuration. I have seen
it three times only, twice in my own practice, and once in that of a
medical friend. One of my cases was fatal, the other ended in
recovery, as did, I believe, the third case. Murchison saw it in only
6 cases, 5 of which were fatal. According to Hoffmann,[66] 16 cases of
suppurative parotitis were found at Basle among about 1600 typhoid
fever patients, 7 of the 16 ending fatally. Parotitis without
suppuration occurred three times. In 15 cases the attack was confined
to one side, 9 times to the right and 6 to the left; in 4 it was
double. Trousseau[67] looks upon these swellings as a very grave
accident, and says that he has scarcely ever seen a case recover in
which it has occurred, either in the course of typhoid fever or any
other disease. Chomel, on the other hand, is said to have regarded
them as critical and auspicious.

[Footnote 66: Quoted by Liebermeister.]

[Footnote 67: _Clinique medicale de l'Hotel Dieu_, t. i. 1861.]

Menstruation occasionally occurs during typhoid fever, and may be
profuse. Bartels,[68] who has investigated the histories of 172
patients in reference to this point, says that the catamenia always
appear if the menstrual period falls within the first five days of the
fever, and that they do so in two-thirds of the cases if they are
expected between the sixth and fourteenth days. On the other hand,
menstruation does not occur if the time for it falls in the third
week. He says also that the catamenia generally appears about the time
they are expected, or later, and very seldom earlier. Liebermeister,
on the contrary, says that they often occur prematurely. Other uterine
hemorrhages seldom occur, and never in those who have ceased to
menstruate or in whom the function has not been established.

[Footnote 68: _Petersb. Med. Wochenschr._, 1881.]

Suppuration of Bartholini's glands is said by Speilman to have taken
place in one case.[69] In the fourth week the patient complained of
violent pains in the right nympha, which, upon examination, was found
to be swollen. A tumor as large as a nut, which was red and painful on
pressure, could also be felt in the vagina.

[Footnote 69: _Arch. generales_, Mars, 1882.]

Pregnancy was formerly thought to confer an entire immunity from
typhoid fever, but recent and accurate investigations have shown that
if this immunity really exists, it is only relative, not absolute.
Gusserow[70] says that the disease is more frequently met with in the
first half than in the latter half of pregnancy. Abortion under these
circumstances commonly occurs. Gusserow says that it takes place in
from 60 {297} to 80 per cent. of the cases. He believes it to be due
to the high temperature, which causes the death of the foetus, which
is then expelled from the uterus. In a few cases, however, the child
is born living. Of Murchison's 14 cases, 10 recovered, and two of the
ten patients carried the child, at the fourth and eighth months
respectively, throughout the attack. All the others miscarried or
aborted, only one of them being delivered of a living child. Out of 18
pregnant women[71] treated in the hospital of Basle for typhoid fever,
between the years 1865 and 1868, 15 miscarried or aborted. In the
three years following the introduction of the anti-pyretic treatment
only five cases of abortion occurred, and but one of these proved
fatal. This accident generally happens during the second or third week
of the fever. It is always a serious complication, and if it occurs in
the first three months of pregnancy it generally gives rise to profuse
hemorrhage, which is usually followed by a fall of temperature as
marked as that observed in hemorrhage from the intestines. Just as in
the latter case, the fall is only temporary, being soon succeeded by a
rapid rise of the temperature to its former height, or even beyond it.

[Footnote 70: _Schmidt's Jahrbuch_, Bd. 193, No. 1, 1880, from _Berl.
klin. Wochenschr._, 1880.]

[Footnote 71: Liebermeister, _loc. cit._]

The danger of bed-sores occurring in typhoid fever is in consequence
of the impaired nutrition of the tissues, the length of time the
disease lasts, and the great emaciation which usually attends
it--greater than in any other acute disease. They constitute a very
serious and troublesome complication, and may occur on any part of the
body subjected to pressure, but are most frequent over the sacrum and
trochanters. Oedema of the lower extremities from feebleness of the
circulation is occasionally observed in the convalescence from
protracted attacks. Lendel has published a series of 7 cases observed
at Rouen, in which the entire body became very oedematous in the
second or third week of the attack or during convalescence. In none of
the cases was the urine albuminous. All the patients recovered except
one, who died of peritonitis. Similar cases have been reported by
other observers. Barthez and Rilliet have seen several cases in
children.

Periostitis is an occasional sequel. I have seen it in one case only.
Sir James Paget,[72] who appears to have met with it in several cases,
says that it never occurs in the continuity of the fever, but always
when the patient is apparently convalescent, when his temperature is
normal and constant, and he is beginning to move about and to grow
stronger and stouter. Its most usual seat is the tibia, but it is also
met with in the femur, ulna, and parietal bone. Except in one case,
Sir James has never seen it in more than one bone in the same person.
It is always circumscribed within a space of from one to three inches
in extent, and usually subsides without necrosis or other abiding
change of structure; but in some cases the patient has remained for
some time subject to repeated attacks of pain and swelling of
periosteum. In the few cases, he says, in which the periostitis is
followed by necrosis the extent of dead bone has always been less than
that of the inflammation over it. Murchison, however, refers to two
cases of necrosis of the tibia, to one of the temporal bone, and to
two in which extensive necrosis of the lower jaw occurred. Gay[73]
also reports a case of extensive necrosis of the thigh-bone in a child
three years old, following an attack of typhoid fever.

[Footnote 72: _St. Bartholomew's Hospital Report_, vol. xxi.]

[Footnote 73: _Path. Trans. Lond._, vol. xx., p. 290.]

{298} Very frequently after an attack of typhoid fever the patient
evinces a tendency to grow stout, which is either continuous or else
is gradually lost after he fully recovers his health. This increase in
flesh is not always accompanied by a corresponding gain in physical
strength, and he may remain for a long time after convalescence is
apparently complete incapacitated for much bodily or mental exertion.
Sometimes, on the other hand, the patient, instead of gaining flesh
and strength, may continue weak and emaciated, even when he is taking
a full amount of nourishment, which he is, however, unable to
assimilate. Cases of this kind may terminate in phthisis, but they
occasionally prove fatal, without any discoverable lesion after death
except an abnormally smooth appearance of the mucous membrane of the
ileum and a shrivelled condition of the mesenteric glands.[74]

[Footnote 74: Murchison.]

Patients suffering from typhoid fever may occasionally contract other
specific diseases. Murchison has notes of eight cases in which the
eruption of this disease coexisted with that of scarlatina, and says
that it was not uncommon in the London Fever Hospital for a patient
suffering from the former disease to contract the latter. Similar
cases are recorded by other observers. Typhoid fever may also be
complicated with rubeola, pertussis, diphtheria, variola, and
vaccinia. I have repeatedly seen children convalescent from typhoid
fever in the hospitals of Paris contract one or other of the eruptive
fevers.

VARIETIES.--A great variety of forms of typhoid fever has been
described by various authors, but as many of them present few points
of difference from the usual form of the disease, it will not be
necessary to discuss them at any length. They derive their names from
some peculiarity of the mode of seizure, from the prominence of some
one symptom or set of symptoms, or from the presence of complications.
They are--(1) The adynamic form, in which prostration is marked in the
beginning and throughout the attack. (2) The ataxic or nervous form,
which is characterized by the predominance of delirium, subsultus
tendinum, and other nervous symptoms. (3) The hemorrhagic form, in
which there is a special tendency to hemorrhage from the different
mucous membranes. (4) The abdominal form, in which the abdominal
symptoms, such as diarrhoea and tympanites, are well developed. (5)
The thoracic form, so called from the presence of some thoracic
complication. (6) The gastric or bilious form, in which the disease is
complicated at its commencement by gastro-intestinal catarrh. La forme
muqueuse of French authors is probably identical with the above. (7)
The acute form, in which the disease begins abruptly and with great
violence, and runs a very rapid course, terminating usually in death
before the end of the first week or early in the second, before
ulceration can have taken place. Delirium is an early and prominent
symptom in this form, so that it has sometimes been mistaken for
meningitis.

Certain forms of the disease deserve a little fuller consideration.
One of the most important of these is the abortive form, in which, as
its names implies, the fever is cut short in its course, and in which
there is every reason to believe that infiltration of Peyer's glands
takes place as usual, but that the subsequent course of the disease is
different, the glands undergoing resolution instead of advancing to
ulceration. The majority {299} of observers agree that in the
beginning there is nothing to distinguish such attacks from those
which follow their usual course. Liebermeister and Jaccoud state,
however, that their commencement is usually more abrupt than in the
ordinary variety, the former asserting that the temperature generally
reaches its maximum earlier, and the same opinion is expressed by
other authors. They are occasionally characterized by severe symptoms,
including a high temperature. In the few cases which have come under
my own observation the symptoms have been mild, but they were
sufficiently developed to leave no doubt on the mind as to the nature
of the disease. In a case which aborted on the twelfth day there were
hebetude, diarrhoea, tympany, and rose-colored spots persisting even
after the subsidence of the fever. Constipation would appear, however,
to be more frequent than diarrhoea in this class of cases. The
subsidence of the fever may occur at any time between the seventh and
fourteenth days; Griesinger has seen it occur as early as the fifth
day. Sometimes the defervescence occurs abruptly, with copious
perspiration; at others it is gradual and similar to that which takes
place in ordinary attacks. Between the abortive form of typhoid fever
and simple continued fever there are, of course, many points of
resemblance, but cases of the former may generally be recognized by
the presence of this rose-colored eruption and enlargement of the
spleen, or, where these are absent, by their occurring in the same
house or under the same circumstances as typical cases of the disease.

Liebermeister has called attention in his article on typhoid fever in
_Ziemssen's Cyclopaedia_ to a class of cases which, he thinks, is also
caused by the typhoid infection, and of which the prominent feature is
the insignificance of the fever or the entire absence of it which
characterizes them. Such cases appear to be of frequent occurrence in
Basle. Many of them, he says, never show during their entire course
any rise of the temperature, or occasionally a slight elevation only,
but an enlargement of the spleen could generally be detected, and
occasionally an unmistakable rose-colored eruption. The action of the
bowels was usually irregular; sometimes there was diarrhoea, and
sometimes, on the other hand, obstinate constipation. The other
symptoms were prostration, pains throughout the body, often headache,
persistent loss of appetite, with more or less swollen and furred
tongue, and markedly diminished frequency of the pulse, which
disappears with convalescence, while its quality is not appreciably
altered. The long duration of an apparently trifling indisposition he
considers as especially characteristic. Cayley also refers to cases,
and even epidemics, of typhoid fever in which the temperature has been
below the normal throughout the whole course of the attack. Strube[75]
had the opportunity of observing such an outbreak during the siege of
Paris by the Germans in 1870. "In many of the cases," he says, "the
temperature throughout was subnormal, and in others never exceeded the
normal point. The roseola was usually profuse; the nerve symptoms were
of marked severity, and were in inverse ratio to the temperature,
consisting of violent delirium alternating with stupor; the duration
of the fever was very short, defervescence usually taking place at the
end of a fortnight. Of the 23 fatal cases, in 20 death took place
during the first fourteen days. The abdominal {300} symptoms were
slight, but the characteristic lesions were found on post-mortem
examination. All the cases were characterized by great prostration.
These cases presented some features which were probably due to this
peculiarity of the temperature; thus, the pulse was but little
accelerated, seldom exceeding a hundred; the tongue did not become dry
and brown; and the enlargement of the spleen was either absent or much
less marked than usual. Strube attributed the peculiar features of
this epidemic to the depressed condition of the troops; they had been
exposed to great hardships on the way to Paris, over-fatigued by
forced marches, and very insufficiently supplied with food."

[Footnote 75: Quoted by Dr. Cayley.]

A mild form of the disease has been described by certain authors, in
which the symptoms, although not severe, are characteristic, and in
which there is therefore, with due care, little danger of making a
mistake in diagnosis. It therefore seems an unnecessary refinement to
set apart such cases under a separate head.

The latent form, or the typhus ambulatorius of the Germans, is of more
importance from the fact that the symptoms are so mild, or that so
many of the ordinary symptoms are wanting or masked by those due to
complications, that there is great danger of regarding the attack as
of little moment. In many cases there is no symptom present but
prostration and fever to indicate that the patient is ill, and these
may be so slight that he may positively refuse to go to his bed, and
may even insist upon pursuing his ordinary avocation, in the midst of
which he is often suddenly seized with alarming symptoms, such as
violent delirium, intestinal hemorrhage, or, what is more common,
those due to perforation of the bowel. Still, even in these cases a
careful examination will often disclose the presence of some symptom
which had failed before to attract attention, and which will often
reveal to us the true nature of the disease. I was myself the subject
of such an attack nearly twenty years ago. Supposing that the
excessive prostration from which I was suffering was due to overwork
at a large army hospital in the neighborhood of Philadelphia, I
determined to seek repose in travel and in change of scene. On the eve
of doing so I fortunately sent for a medical friend, who, after a
thorough investigation of my symptoms, succeeded in finding a few
rose-colored spots upon my abdomen. The attack subsequently ran a mild
but well-marked course. Occasionally, the symptoms due to a
complication so predominate over those arising from the disease itself
that they completely mask it. I have known bronchitis so severe as to
divert in this way the attention of a skilful diagnostician from the
primary disease. When vomiting, together with other symptoms of
hepatic derangement, is especially prominent in the beginning of
typhoid fever, the mistake is not infrequently made of attributing
these symptoms to a "bilious attack."

TYPHO-MALARIAL FEVER.--Under this name, which was originally suggested
by J. J. Woodward, Surgeon U.S.A., early in the summer of 1862, as a
designation for a class of cases in which the symptoms of typhoid
fever are associated with those of remittent, and which was especially
common among the soldiers of the United States Army during the late
Civil War, are probably included at least two distinct conditions:
1st, remittent fever, in which the disease, on account of the
depressing circumstances surrounding the patient, assumes {301} a
typhoid form; and, 2d, typhoid fever, occurring in a patient who has
also been exposed to malarial influence. This association of diseases
is of course not new, or even undescribed before this name was
suggested for it. Woodward thinks that he has found enough in the
description of Roderer and Wagler to justify him in concluding that
the epidemic which occurred at Gottingen in 1762 was really of this
character. There would seem also to be no doubt from the descriptions
of Dawson[76] and Davis[77] that the fever which decimated the British
army in the Walcheren expedition was typhoid fever, modified by the
malarial influence to which the soldiers were subjected. The latter of
these authors says that the ileum and jejunum in the bodies of those
who died of this disease were frequently found interspersed with
tubercles, inflamed and ulcerated in different parts.

[Footnote 76: _Observations on the Walcheren Diseases_, Ipswich, 1810,
by G. P. Dawson.]

[Footnote 77: _A Scientific and Popular View of the Fever of
Walcheren_, J. B. Davis, London, 1810.]

In our own country the occasional association of these two diseases
has also long been recognized. Drake describes it under the name of
remitto-typhoid, and Dickson seems to have been perfectly familiar
with it, for he says that typhoid lesions will sometimes be found in
the bodies of those dead of bilious remittent. Levick recognized the
presence of the symptoms of both diseases in some patients who were
under his care as early as the spring of 1862, and proposed the name
of miasmatic typhoid fever for this class of cases in the following
June.[78] Meredith Clymer has also frequently met with cases in which
the symptoms of the two diseases were coexistent.[79]

[Footnote 78: _Med. and Surg. Reporter_, June 21, 1862.]

[Footnote 79: _The Science and Practice of Medicine_, by William
Aitken, M.D., 3d Amer. ed.; with additions by Meredith Clymer, M.D.,
Philadelphia, 1872.]

As is indicated by the name given to it, the symptoms in this form of
typhoid fever are modified by the presence of malarial poisoning. The
cases always manifest a decided tendency to periodicity, the evening
exacerbations are more decided than in the ordinary form, the
remissions are often ushered in with a profuse sweating, gastric and
hepatic derangements are more marked, and headache is more severe.
There is frequently less mental hebetude or dulness than in ordinary
typhoid fever. In some of the cases observed by Levick[80] the
symptoms were those of pernicious congestive remittent fever, such as
copious serous discharges, not unlike those of Asiatic cholera,
colliquative sweats, and other symptoms of exhaustion.

[Footnote 80: _Amer. Journal of the Med. Sci._, April, 1864.]

TYPHOID FEVER IN CHILDREN.--It was formerly thought that infants and
very young children were not often the subjects of typhoid fever, but,
so far is this opinion from being correct, it is now known that they
are especially liable to suffer from it. The rose-colored eruption is
more often wanting in them than in adults, and the fever more apt to
assume a distinctly remittent type; and hence, no doubt, the
difficulty which is often experienced in diagnosticating this fever
from other forms of fever in children. There is no doubt that many
cases which have been described by authors under the head of infantile
remittent fever are really examples of typhoid fever modified simply
by the age of the patient. It may occur in infants not more than six
months old, and is not infrequent in {302} children of two or three
years of age. Henoch,[81] who has had the opportunity of observing a
large number of cases, says that the rise of temperature is commonly
more abrupt in children than in adults, and that the disease generally
runs its course in a shorter time. The pulse is more frequent, and may
be as high as 144 in cases in which the prognosis is not grave.
Dicrotism is very rare. Slowness and irregularity of the pulse, like
that observed in basillar meningitis, he has never seen. The nervous
symptoms are not so pronounced even when the temperature is high, and
they bear no relation in severity to the height of the temperature.
Diarrhoea in the cases observed by Henoch was often absent during the
whole course of the attack, and the stools were often brownish or
greenish instead of yellow.

[Footnote 81: _Charite Ann._, 1875.]

TYPHOID FEVER OF AGED PERSONS.--The modifications which the disease
undergoes when it occurs in patients advanced in life are precisely
those to be expected from the diminished activity of the processes of
life in them, as compared with those of younger persons. The febrile
movement is generally prolonged, although of low grade, the
temperature rarely rising high, and frequently during convalescence
sinking below the normal. The diarrhoea is commonly not so severe, the
delirium so violent, or the rose-colored eruption so often present. On
the other hand, adynamic symptoms, such as excessive prostration,
tremors, subsultus tendinum, and the like, are frequently prominent
from the beginning of the attack.

Several authors, among whom may be mentioned Arnat,[82]
Hornburger,[83] and Greenhow,[84] have described a renal form of
typhoid fever. In this form the urine is blood red in color or like
dark broth. It often contains albumen during the first week of this
disease, usually hyaline or more or less granular casts, and
occasionally red blood-discs, white cells, epithelia of kidneys and
bladder, and epithelial detritus. The specific gravity is high, and
the quantity is usually diminished. The prominent symptoms are pain in
the region of the kidneys, oedema of face, tense and frequent pulse,
great prostration, profuse epistaxis, violent delirium, and
hyperpyrexia. The temperature may be 105.8 degrees. On the other hand,
the intestinal symptoms are less marked. In fatal cases the lesions of
intestinal nephritis have been found at the autopsy.

[Footnote 82: Thesis, _Sur la Fievre typhoide a forme renale_.]

[Footnote 83: _Berlin klin. Wochenschrift_, 1881.]

[Footnote 84: _Transactions of Clinical Society of London_, 1880.]

RELAPSES.--Much difference of opinion will be found to exist among
authors in regard to the frequency with which relapses occur in
typhoid fever, and this difference does not appear to be due to any
greater frequency of this accident in some countries than in others,
since Liebermeister met with them in 8.6 per cent. of the cases
treated at the hospital at Basle, while, according to other German
observers quoted by him, they occur in 6.3 per cent. (Gerhardt), in 11
per cent. (Baumler), and in 3.3 per cent. (Biermer). Murchison noted
them in 80 of 2591 cases in the London Fever Hospital, or in 3 per
cent., and Maclagan in 13 of 128 cases at Dundee, or in 10 per cent.
about. Immermann[85] of Basle says that they occur in 15 per cent. of
the cases, and that in very unfavorable years the proportion may be as
high as 18 or 19 per cent. Prof. Henoch[86] observed relapses in 16
cases out of 96, or 16.6 per cent. In my own {303} practice they have
not been very numerous. I find that in 80 cases of which I have full
notes they are recorded five times, or in 6.25 per cent., and I
believe this ratio correctly represents the frequency with which they
have happened in all the other cases which have come under my care.
Part of this difference of opinion is unquestionably attributable to
the fact that under the term relapse are sometimes included two
distinct conditions: (1) Mere recrudescences of fever, which occur
during the stage of defervescence or that of convalescence, and which
are provoked by errors of diet, mental or bodily fatigue, or some
other irritating cause. They usually last a day or two, and are
entirely distinct from (2), true relapses, in which all the
characteristic symptoms of the primary attack are reproduced, and
which commonly occur some time after the disease has apparently run
its course. There is occasionally no distinct apyretic interval
between the two attacks, but in by far the greater number of instances
the relapse occurs in the second or third week, or even later, after
the establishment of convalescence. In 20 cases reported by W. M. Ord
and Seymour Taylor[87] the relapse occurred in the third week of the
disease in 1; in the fourth week in 5; in the sixth week in 3; in the
seventh week in 7; in the eighth week in 3; in the ninth week in 1.
James Jackson refers to a case in which the date of the relapse is not
given, but in which he was able to detect the rose-colored eruption in
the sixty-sixth day[88] from the commencement of the disease. In my
five cases the relapse occurred on the seventh, eighth, ninth,
eleventh, and twentieth day after the apparent establishment of
convalescence. In these cases the duration of the relapse was 11, 13,
17, 20, and 13 days respectively. The highest temperature noted in any
of the relapses was 105 degrees, which occurred in two cases. In both
of these this temperature had also occurred in the original attacks.
In one of the others, however, a temperature of over 104 degrees F.
was repeatedly observed in the relapse, while in the primary attack it
had never risen above 102 degrees.

[Footnote 85: _Schweiz. Corr. Bl._, viii. 1878.]

[Footnote 86: _Charite Ann._, ii. 1875.]

[Footnote 87: _St. Thomas's Hospital Report_, vol. ix., London, 1879.]

[Footnote 88: Since the above was written I have had under my care a
case of typhoid fever in which a third relapse occurred nearly four
months after the patient, a woman aged thirty years, was first taken
ill. The following is a brief abstract of the history of this
remarkable case: The original attack began about Sept. 20, 1883, was
of moderate severity, and lasted between three and four weeks.
Convalescence, which seems to have been nearly complete, as the
patient had left her bed, was interrupted on Nov. 1st by a relapse,
during which she was admitted into the Pennsylvania Hospital. This
relapse was severe, and before it had entirely run its course was
itself interrupted, on Nov. 17th, by an intercurrent relapse, which
lasted two weeks. During these two relapses extensive bed-sores formed
upon the nates, occasioning more or less irritation and consequent
febrile reaction. On Jan. 11, 1884, a third relapse occurred. This
relapse was accompanied by diarrhoea, rose-colored spots, tympany, dry
and brown tongue, and other characteristic symptoms of typhoid fever,
the diagnosis being fully concurred in by my colleague, Dr. Morris
Longstreth, who saw the case with me. Convalescence was again
interrupted on Feb. 13th by fever, which continued for two weeks, but
which possessed none of the characters of typhoid fever, and was
clearly due to imprudence on the part of the patient. The patient is
now (April 25, 1884) entirely well, and will shortly be discharged
from the hospital.]

The onset of a relapse is usually much more abrupt than that of the
original attack. It is rarely preceded by prodromata. The temperature
rises more rapidly and attains its maximum earlier, which may be much
greater than in the original attack. In one case under my care it
reached 105 degrees on the evening of the first day, and temperatures
of 103.5 degrees and 104 degrees on the evening of the second day are
not infrequent.

{304} The rose-colored eruption appears earlier. In 38 cases
investigated by Murchison with reference to this point, it appeared on
the third day in 7; on the fourth in 8; on the fifth in 7; on the
sixth in 2; on the seventh in 12; and at a later date in 2. In the
case the history of which is given below it was detected on the second
day. The delirium also comes on sooner. The relapse is usually less
severe, and is of shorter duration, than the primary attack. All my
cases terminated in recovery. Occasionally, however, it is much more
severe. In one case in which the primary attack was so mild that the
patient could scarcely be persuaded to remain in bed, the relapse was
so severe that for many days it was uncertain whether the patient
would recover. In another intestinal hemorrhages to an alarming extent
occurred on two occasions. Moreover, of Murchison's 53 cases, 7 were
fatal; in 2 of the cases death was due to perforation; in 2 to
peritonitis, induced by infarction of the spleen; and in 1 to
abortion; and of Ebstein's 13 cases, 3 were also fatal. Occasionally,
a second, and it is said even a third, relapse is noted. In one of Da
Costa's cases hemorrhage from the bowels took place during a second
relapse.

[Illustration: FIG. 15. Pulse.]

The following histories and temperature charts illustrate the
prominent peculiarities of relapses occurring in typhoid fever:

TYPHOID FEVER (with a relapse).--G---- L----, aet. 20, single, seaman,
Italian, admitted March 6, 1878; April 30, 1878, left in ward. Patient
is unable to speak English. The following history is obtained through
an interpreter: His family history is good, and he is naturally a
healthy man, never having had any serious illness--no venereal
disease, no cough or rheumatism, no intermittent fever, and he has not
been in the habit of drinking to excess. His vessel has been lying off
Gloucester Point, and two seamen have recently been similarly affected
on another vessel anchored near by. For about two weeks he has had
malaise, but not until three days ago was he so ill that he was
obliged to give up work. He was then taken with cough, chills followed
by fever, diarrhoea, headache, and pain in the abdomen. Has had no
epistaxis or vomiting.

Upon admission patient has fever, his face is flushed, his tongue
coated with a brown fur in the centre, dry, fissured, and red and
glossy at the tip and edges. He has hebetude and some delirium, though
not very active; he is deaf. His abdomen is somewhat tense and
tympanitic, and covered with very numerous rose-colored spots, which
disappear momentarily on pressure; they are also distributed over
thighs and chest. There seems to be no tenderness on pressure over
abdomen, and there is no gurgling felt. Has moderate diarrhoea, having
about three stools daily, which are light yellow in color and are
loose and fetid. Urine cloudy orange red, acid, 1021. No albumen.

{305} _3.7_. Ord. Ol. Terebinth. gtt. x; Acid. Muriat. dil. gtt. v
every two hours, with Quinine gr. viij daily, and restricted diet.

_3.8_. Tongue not so dry; is better. Whiskey fl. oz. ij.

_3.9_. Temperature elevated. Ord. to be sponged.

_3.10_. Has had four stools in the last twenty-four hours. Some
sonorous rales over chest posteriorly. Sponging to be repeated when
temperature rises.

_3.11_. There is some subsultus. There are more numerous rales heard
over chest posteriorly.

Ord. whiskey fl. oz. v daily; turpentine stupes to chest. His
diarrhoea is better; considerable hebetude.

_3.12_. Tongue is not so dry, and is cleaner. The spots over his body
are beginning to assume more the appearance of petechiae. They are
found everywhere on his body. Has had but one stool within the last
twenty-four hours.

_3.13_. He is brighter; skin feels better; tongue cleaner; pulse but
80. Fewer rales heard in chest. No change in his treatment.

_3.14_. Spots disappearing. Two stools in last twenty-four hours, not
so loose in character. Pulse dicrotic.

_3.15_. There is no tympany. Had one natural stool yesterday.
Sudaminae over abdomen.

_3.16_. Doing well. Pulse very slow.

_3.17_. Tongue moist and clean; no diarrhoea.

_3.18_. No diarrhoea; spots are still to be seen, but are fading every
day.

_3.20_. Takes a little lemon-juice, as the gums are disposed to be a
little spongy.

Stop turpentine and muriatic acid.

_3.25_. Bowels somewhat constipated.

Ord. enema of castor oil.

_3.26_. Stop quinine; give whiskey fl. oz. iij only. Allowed chicken
and two eggs daily.

Ord. Tr. Cinch. Co. fl. drachms ij s.t.d.

_4.4_. Slight chill, headache, and pain in side. Temp. 101 degrees.

_4.5_. Temp. normal again; as well as before.

_4.8_. Has been up for a week, and steadily gaining in strength,
except the slight attack on the 4th, when to-day, without his having
taken any indigestible food, or indeed any reason to which it could be
assigned, he was seized with a relapse, his temperature rising to 105
degrees, but being reduced a half degree by sponging.

_4.9_. Spots have again appeared in great numbers, and they are very
large. Last evening his temperature reached 104-3/4 degrees, and was
reduced to 101 degrees by sponging.

_4.10_. Doing very well; spots are still making their appearance.

_4.12_. Diarrhoea not at all excessive.

_4.15_. Spots are very numerous.

_4.20_. Temperature nearly normal.

_4.25_. Doing perfectly well; up and about.

_4.30_. Left in ward, upon completion of my term of service.

{306} [Illustration: FIG. 16. Chart of temperature in typhoid fever
with relapse.--Original attack.]

[Illustration: FIG. 17. Chart of temperature in typhoid fever with
relapse.--Relapse.]

ABORTIVE ATTACK, FOLLOWED BY TYPICAL ATTACK.--Thomas Rogers, October
15, born in Philadelphia, assistant nurse. Admitted {307} January 25,
1883; discharged March 26, 1883, cured. Father died of hemorrhage from
the lungs; mother living and healthy. Two years ago he sustained a
compound fracture of the left leg from a bale of cotton falling on
him; otherwise he has always enjoyed good health. For the past three
months he has been assisting the nurse in the receiving ward of this
hospital. Four days before admission, without unusual exposure, he had
a slight chill, and felt cold for several hours. This was followed by
fever and a feeling of weakness. He also had slight headache and the
bowels were constipated; no epistaxis.

Upon admission patient has a good deal of hebetude, face flushed,
temperature 102 degrees, pulse 106, tongue slightly coated, moist. Has
slight pain in right lumbar region, but no distension of abdomen.
Urine negative.

Ord. quinine gr. viij. daily; liq. ammon. acet. fl. drachms ij. q.q.h.

_Jan. 29th_. More hebetude; tongue more coated with brownish fur, red
at tip; bowels continue costive; opened by an enema.

_31st_. Is brighter and better. One doubtful rose-colored spot seen on
abdomen.

_Feb. 4th_. The morning temperatures for the past two days have been
subnormal and the evening rise is very slight. All the symptoms also
indicate the approach of convalescence.

_6th_. More fever; pulse weaker; functional murmur heard over heart;
sudamina out over abdomen. Ord. whiskey fl. oz. ij.

_8th_. Some fulness of abdomen; had three loose yellowish-colored
stools in the last twelve hours.

_9th_. A few doubtful rose spots out over abdomen and back; sudamina
still abundant.

_10th_. More tympany; numerous rose-colored spots out over abdomen and
back; slight epistaxis and bronchitis.

_11th_. Pulse more feeble; still slight diarrhoea. Increase whiskey to
fl. oz. iv.

_15th_. Has a good deal of hebetude, but no headache; fewer spots;
pulse weaker; temperature lower. Increase whiskey to fl. oz. vj.

_17th_. Temperature high again; most of the spots have disappeared;
slight epistaxis and subsultus; no delirium; bowels not open for two
days.

_20th_. Temperature falling; spots disappearing; still fulness of
abdomen.

_25th_. Temperature has been subnormal for several days, and he is
doing well; tongue cleaning. Has emaciated a good deal, and is weak.

_March 1st_. Is convalescent; tongue has lost its redness.

_8th_. Continues to improve; allowed semi-solid food.

_17th_. Is now quite well; has gained a good deal in flesh, and is
stronger.

{308} [Illustration: FIG. 18. Temperature chart of typhoid
fever.--Abortive attack, followed by typical attack.]

The examination of the bodies of those who have died during a relapse
reveals the presence of two sets of lesions in the cicatrizing ulcers
of the primary attack and the recent ulcerations of the relapse. The
latter are usually less extensive, and are found to be situated at a
greater distance from the lower end of the small intestine, than the
former, for the reason that the Peyer's patches most remote from the
ileo-caecal valve are least apt to be affected in the primary attack.

No satisfactory explanation of these relapses has as yet been
discovered. {309} They occur in patients of both sexes and of all ages
with about the same frequency. They have been attributed to errors of
diet, mental and bodily fatigue, and the like, but, while we know that
causes of this character often provoke recrudescences of fever, and
can understand that they may act as exciting causes of a relapse in
cases in which the predisposition exists, it does not seem possible
that they should by themselves be able to bring back all the
characteristic symptoms of a specific disease. It has been maintained
by some authors that a relapse indicates that a new infection has
taken place; but this hypothesis, even if we admit that it accounts
for those cases in which the patient is allowed to remain in the place
in which he has acquired the disease, does not explain those in which
he is removed during the first attack to a hospital where all the
sanitary arrangements are presumably perfect. Griesinger has
endeavored to explain relapses occurring in hospitals by suggesting
that they may possibly be due to a fresh contagion from other patients
with typhoid fever in the same ward; but this explanation is rendered
improbable by the fact that relapses have occurred when cases have
been thoroughly isolated. As I have already said, during a long
connection with the Pennsylvania Hospital I have only known a single
case of typhoid fever to originate within its walls, although relapses
probably occur in its wards with the same frequency as in other
hospitals. To adopt Griesinger's explanation, it would therefore be
necessary to assume that a patient just recovered from an attack of
the disease is more susceptible to the action of its contagion than
patients suffering from other disease; which seems improbable, to say
the least. It has also been maintained that relapses are due to the
inoculation of the previously healthy Peyer's patches by the typhoid
poison which is thrown off with the sloughs from those first affected.
Maclagan alleges that relapses are more frequently met with in cases
in which constipation is present in the primary attack, a condition
which he regards as favorable to absorption; but this is opposed to
the experience of almost every one who has paid any attention to the
subject. In the cases which have come under my own observation it
certainly was not the case, diarrhoea having been present in all of
them. It is more likely, as suggested by Liebermeister, that part of
the poison remains latent somewhere in the body, not developed,
destroyed, nor expelled during the first attack, but brought later
into activity by some exciting cause. Da Costa adopts this view, and
says that relapses of typhoid fever are not unlike the outbreaks of
malarial fever which occur after worry or fatigue and when there has
been no chance for a fresh infection. Different plans of treatment
have at various times been charged with increasing the predisposition
to relapses. This is especially true of the cold-water treatment, and
the records at the hospital at Basle show that the proportion of
relapses and the number of deaths from them are both increased under
the use of cold water. Liebermeister thinks, however, that this does
not necessarily prove that this treatment favors the occurrence of
relapses, since before the introduction of this plan of treatment many
more typhoid fever patients died in the first attack of the disease.
Employing those cases only for statistical purposes in which the
patients have survived the first attack, he finds that the difference
at once disappears, there being 9 per cent. of relapses before the use
of cold water, and 10.3 per cent. after its use.

{310} Gerhardt[89] asserts that in cases in which relapses occur the
enlargement of the spleen does not diminish during the non-febrile
period that intervenes between the original attack and the relapse.

[Footnote 89: _Ziemssen's Cyclopaedia_, vol. i. p. 193.]

Da Costa[90] has shown that the appearance of the white line and
furrow left by the primary attack, to which attention has already been
drawn, may sometimes be of service to us in diagnosis when we see the
patient for the first time during the relapse. In a case which was
recently under my care their appearance certainly rendered the nature
of the previous illness from which the patient had suffered much
clearer than it would otherwise have been.

[Footnote 90: _Transactions of the College of Physicians of
Philadelphia_, 3d S., vol. iii.]

DURATION.--The mode of invasion of typhoid fever is generally so
insidious, and the first symptoms so little pronounced, that the
patient, even if free from mental hebetude and confusion at the time
when he first comes under the care of a physician, is usually unable
to fix with certainty the time of the beginning of his illness. This
inability is of course most marked in what are known as walking cases,
in which, notwithstanding that the disease is far advanced, the
patient continues to pursue his ordinary avocations or at least
refuses to go to bed. In a few cases, however, either in consequence
of the violence of the first symptoms or from some other cause,
opportunity is afforded to the physician of observing the disease from
its onset. In many others the date of commencement may be
approximately ascertained. The average duration of such cases, if
uncomplicated, has been found to be between three and four weeks.
According to Bartlett, the average duration of 255 cases at the
Massachusetts General Hospital between the years 1824 and 1835,
inclusive, was twenty-two days. It was a little less than this in
patients under twenty-one years of age, and a little more in those
over. As these cases occurred before the introduction into use of the
clinical thermometer, and as the commencement of convalescence is
fixed in them at the time when the patients were able to take a little
solid food, it is possible the fever may have continued in them some
time after convalescence was supposed to have been established. Of 200
cases which ended in recovery, and in which Murchison was able to
ascertain with precision the date of commencement, the duration was 10
to 14 days in 7 cases, 15 to 21 days in 49 cases, 22 to 28 days in 111
cases, and 29 to 35 days in 33 cases. The mean duration of these 200
cases was 24.3 days, while that of 112 fatal cases was 27.67 days.
From the same author we learn that the average stay in hospital of 500
cases which recovered was 31.24 days, and of 100 fatal cases was 16.52
days, while the average duration of the illness before admission in
the 600 cases was 10.78 days. During the twenty years from Jan. 1,
1862, to Dec. 31, 1881, 621 cases of typhoid fever, 121 of which were
fatal, were admitted into the Pennsylvania Hospital. No notes of many
of these cases were taken, and of some of the others the notes are
incomplete or inaccessible, so that they cannot, unfortunately, be
used for the purpose of determining the duration of the disease. The
books of the hospital, however, show the length of time each patient
remained in the wards. From these we learn that the average stay of
the 500 patients who recovered was 43.5 days, while that of the 121
patients who died was only 8.75 days, and that of these a large number
(28) died within {311} 48 hours after their admission to the hospital.
As a rule, patients are retained at the Pennsylvania Hospital until
they are fully able to return to work, while at the English and
continental hospitals it is usual to discharge them when they cease to
need active treatment. This circumstance probably explains the much
greater average duration of the cases admitted to the Pennsylvania
Hospital than that of the cases referred to by Murchison. In the
abortive form the duration of the disease may not exceed ten days, and
there are authors who contend that it may occasionally be very much
less.

Death may occur at almost any time in the course of typhoid fever. I
have never seen it myself take place before the seventh day. Murchison
reports two cases in one of which the disease terminated fatally
within twenty-seven hours of its commencement, and in the other on the
second day. Instances are more numerous in which death has occurred on
the fourth, fifth, or sixth day, but still they are comparatively
infrequent, and, as a rule, the fatal termination takes place most
frequently during the course of the third week. On the other hand,
death may sometimes occur at a very much later period. This is, of
course, the case when it occurs during a relapse, but if the fever
continues after the third week the patient may sometimes die from
exhaustion or from the intercurrence of a complication. Death may also
be the result of a sequela long after the disease has run its course.

DIAGNOSIS.--The insidious invasion of typhoid fever, together with the
absence of pathognomonic symptoms in the beginning, always renders the
diagnosis difficult, and sometimes impossible, during the first week.
Still, even at this time the existence of the disease may be suspected
if the frequent use of the thermometer reveals from day to day a
gradual increase of the fever and the existence of evening
exacerbations followed by morning remissions, the temperature rising
each evening from a degree to two degrees higher than it had done the
preceding evening. If in addition to this character of the pyrexia
there are diarrhoea with ochrey-yellow stools or an increased
susceptibility to the action of cathartic medicines, epistaxis,
enlargement of the spleen, slight fulness of the abdomen, with
tenderness and gurgling in the right iliac region, slight hebetude and
some confusion of ideas upon awakening, the diagnosis becomes more
probable. During the next week the symptoms are usually much more
characteristic. The presence of marked abdominal symptoms, together
with the eruption of rose-colored spots, will generally render the
recognition of the disease at this time an easy matter. There are,
however, a few cases in which no rose-colored spots can be found, and
in which the abdominal symptoms, if they exist at all, are so little
marked that they do not arrest attention. Even in these cases the
temperature record, when carefully studied, will often throw a good
deal of light upon the nature of the disease. If the febrile movement
resembles that usual in typhoid fever, if it has continued for more
than a week, if the patient has not been recently exposed to malarial
influences, and presents no symptoms of local disease, the diagnosis
may still be made with at least an approach to certainty.

The following are the diseases which are most likely to be mistaken
for typhoid fever:

Typhus fever has a course which is so essentially different from {312}
that of typhoid that in well-marked cases it would scarcely be
possible to mistake one for the other. Cases, however, do occur which,
in consequence of a very profuse and dark-colored eruption in the
latter, or of the existence of abdominal symptoms in the former,
present at first a good deal of difficulty in diagnosis. The invasion
of the former is more abrupt and its duration shorter than in typhoid
fever. The eruption is usually also much more copious, and appears in
the former as early as the fourth, fifth, or sixth day, while that of
the latter is rarely observed before the seventh day. The fever in the
former is much more nearly continued in type than that of the latter.
Defervescence occurs in the former by crisis; in the latter, by lysis.
The expression of the physiognomy is different in the two diseases. In
typhus there is a uniform dusky hue of the face, with injection of the
conjunctivae and contraction of the pupils. In typhoid fever the
pupils are often widely dilated, the conjunctivae clear, and the face
pallid, with the exception of a circumscribed flush on each cheek.
Diarrhoea is much less frequent in the former than in the latter, and
when it does occur is not accompanied by ochrey-yellow stools.
Epistaxis, tympanites, pain, and gurgling in the right iliac region,
and intestinal hemorrhage, common symptoms in the latter, are very
infrequently met with in the former. On the other hand, petechiae and
vibices, which are of almost constant occurrence in the former, are
rarely met with in the latter. The circumstances also under which the
two diseases are contracted are different. Typhus originates from
overcrowding or is due to direct contagion. The origin of typhoid
fever is often involved in more obscurity, but it can generally be
traced either to a polluted water-supply or to defective drainage.

Relapsing fever, with due care, is not likely to be confounded with
typhoid fever. The abrupt commencement of the former, the high fever,
lasting for from five to seven days only, and terminating by crisis
with a profuse sweat, and the period of complete apyrexia of a week's
duration, followed by the relapse in which the temperature rises even
higher than in the primary paroxysm, and which also terminates by
crisis, form a chain of symptoms which has no counterpart in the
latter. The mind in relapsing fever is usually clear, there being none
of the hebetude and mental confusion commonly observed in typhoid
fever. The rose-colored eruption is, moreover, wanting, and diarrhoea
and tympanites are absent. On the other hand, jaundice and tenderness
in the epigastric zone are more common than in typhoid fever.

Influenza sometimes, Murchison says, when epidemic, closely simulates
typhoid fever, but as the two diseases occur in this country the
resemblance between them is not often sufficiently strong to lead the
careful observer astray. In both there are fever, prostration,
sleeplessness, delirium and sweating, and occasionally deafness,
diarrhoea, epistaxis, and a dry red tongue; but the onset of the
attack in the former is more abrupt, its duration shorter, and
subsequent convalescence more rapid than in typhoid fever. The
prostration, too, is more decided in proportion to the degree of fever
present. Coryza and bronchial catarrh are much more marked symptoms in
the former than in the latter, while hyperaesthesia of the surface,
which is present in almost every case of influenza, is only rarely met
with in typhoid fever.

Remittent and typhoid fevers often prevail together in the malarious
{313} districts of this country, and, as they present many points of
resemblance, they are sometimes with difficulty distinguished from
each other. They both may begin with nausea and vomiting; abdominal
and cerebral symptoms are common to both, and so is enlargement of the
spleen. The typhoid state may supervene in either, and in both the
febrile movement is remittent in character. In remittent fever,
however, the remissions are more marked, and are usually accompanied
with more profuse sweating, than in typhoid fever. Jaundice and other
symptoms of hepatic derangement are also more common, and the pains in
the back and limbs are more frequent and more severe. The effect, too,
of quinine in producing a permanent reduction of the temperature, is
generally more decided. On the other hand, the rose-colored eruption
of typhoid fever is never present in pure remittent fever.
Occasionally, in cases of the variety of typhoid fever known as
typho-malarial fever, the symptoms of the latter may be so prominent
as entirely to mask those of the former. In such cases the discovery
of a few rose-colored spots somewhere on the surface will clearly
reveal the true nature of the disease.

Epidemic cerebro-spinal meningitis differs from typhoid fever by its
more abrupt invasion, by the retraction of the head which rapidly
supervenes, and by the appearance a short time afterward upon
different parts of the body of petechiae, which are not likely, even
at first, to be mistaken for the rose-colored spots of typhoid fever.
The fever has, moreover, no constant character, but is remarkable, on
the contrary, for its great irregularity. The duration of the disease
is in fatal cases much shorter, death taking place not infrequently
within the first week, and occasionally as early as the second or
third day. On the other hand, the duration in cases which recover may
be even longer than in typhoid fever.

Simple continued fever may readily be mistaken in the beginning for
typhoid fever, especially in those cases complicated by diarrhoea,
but, as a general rule, the different character of the febrile
movement, its more abrupt commencement and termination, and its
shorter duration, together with the absence of the rose-colored
eruption, will usually serve to distinguish it.

The eruptive fevers are always readily distinguishable at the period
of invasion from typhoid fever, and the mistake of confounding them
with the latter disease may generally be avoided by a close study of
the character of the pyrexia. In the eruptive fevers the temperature
rises abruptly, frequently attaining its maximum in the course of
twenty-four hours, and sometimes in very much less time. There are
also in all of them early symptoms which indicate pretty clearly their
true nature, as, for instance, the sore throat of scarlatina, the
naso-pulmonary catarrh of measles, and the rachialgia of small-pox.
The uncertainty, moreover, is of short duration, as the characteristic
eruption appears in all of them before the fourth day.

Acute tuberculosis of the lungs is the condition which in my
experience has been the most difficult to distinguish from typhoid
fever. Indeed, in some cases which have come under my observation
physicians of recognized skill as diagnosticians have been unable to
make the discrimination until after the death of the patient. Muscular
prostration, a dry brown tongue, delirium, stupor, bronchitic rales,
dyspnoea, and even cyanosis, are symptoms frequently met with in both
diseases, so that when the {314} rose-colored eruption and enlargement
of the spleen happen to be wanting in typhoid fever, or diarrhoea and
tympany present in acute tuberculosis, as they may be, the distinction
is often impossible. The diagnosis may, however, even in these cases,
be sometimes made after a careful study of the temperature range,
which in acute tuberculosis is irregular and rarely presents any
resemblance to that which is typical of typhoid fever.

Acute tubercular meningitis has also many symptoms in common with
typhoid fever, such as high fever, headache, vomiting, delirium, and
stupor, but in the former disease the rose-colored eruption,
epistaxis, enlargement of the spleen, and intestinal hemorrhage do not
occur. Diarrhoea is also rare, and the abdomen, instead of being
tympanitic, is flat, and in many cases even scaphoid. The headache,
too, is much more acute than in typhoid fever, and is very apt to be
associated with retraction of the head. Here, again, the frequent use
of the thermometer will yield very important results in diagnosis, as
the temperature range in tubercular meningitis is always irregular and
does not present any resemblance to that usually observed in typhoid
fever.

Several of the inflammations, especially when associated with the
typhoid state, have so many symptoms in common with typhoid fever that
they may very readily be mistaken for one another by a careless
observer. I have known, for instance, the general disease to be
entirely overlooked in a case of typhoid fever complicated by
pneumonia, and, on the other hand, it has sometimes been supposed to
be present in a case of pure typhoid pneumonia. Gastro-enteritis is
another disease which is also occasionally confounded with typhoid
fever. The diagnosis in these cases will rest principally upon the
presence or absence of epistaxis, enlargement of the spleen,
tympanites, the rose-colored eruption, and of a temperature range
presenting some similarity to that usual in typhoid fever.

Trichiniasis is not likely to give rise to much difficulty in
diagnosis, for although vomiting, diarrhoea, and the typhoid state
occur in it as well as in typhoid fever, the former disease may
usually be recognized by the severe muscular pains and the local
oedema which are constant accompaniments of it, and by the absence of
the characteristic symptoms of the latter.

PROGNOSIS.--There is no other disease in which the physician should be
more careful in making a positive prognosis than in typhoid fever. On
the one hand, accidents of a fatal character frequently occur in cases
which are apparently progressing favorably, and, on the other,
recovery has often taken place after all hope of it had been
abandoned. But, although it is impossible to foretell with absolute
certainty the result in any particular case, there are certain
symptoms which furnish very important indications for prognosis, and
the proper appreciation of which will generally enable us to arrive at
a correct conclusion as regards the gravity of the disease. Prominent
among these is the character of the pyrexia. A fever characterized by
high temperature should always give occasion for great anxiety. This
is very fully shown by the statistics of the hospital at Basle. Thus
of those patients in whom the temperature did not reach 104 degrees,
only 9.6 per cent. died; of those in which it reached or exceeded 104
degrees, 29.1 per cent. died; and, finally, of those in whose axilla
the temperature rose to or above 105.8 degrees, more than half died.
{315} Wunderlich has arrived at very nearly the same conclusions, for
he says that the prognosis is very unfavorable when the temperature
rises to 106.16 degrees, that the deaths are almost twice as numerous
as the recoveries when it rises to 107.06 degrees, and that recoveries
are rare when it rises to 107.24 degrees. Murchison has, however,
known recovery to follow a temperature of 108 degrees. The highest
temperature recorded in any of my cases was 106 degrees F. In this
case, which proved fatal, the temperature reached 105 degrees F. five
times. In three other cases, in all of which recovery took place, a
temperature of 105.5 degrees F. was observed. In twelve cases the
temperature reached 105 degrees F. on more than one occasion. Six of
these ended fatally; in the others the patients recovered.

The prognosis is more unfavorable in a fever in which the temperature
is continuously high, and in which the morning remissions are slight
or wanting, than in one in which the daily fluctuations are greater,
even though the temperature may reach a higher point during the
evening exacerbations in the latter variety than is attained at any
time in the former. Occasional remissions, even if produced by quinia
or other remedies, are to be regarded as favorable omens, as they
indicate that the fever tends to subside. A high morning temperature
ought, therefore, to give rise to more alarm than a high evening
temperature. The prognosis is grave when the morning temperature rises
to 104 degrees or is persistently above 103 degrees. Murchison says
that recovery is rare after a morning temperature of 105 degrees.
Fiedler[91] saw, with a single exception, all patients die whose
temperature in the morning rose to or exceeded 106.25 degrees, while
of those whose temperature in the morning rose to 105.44 degrees, if
only on one day, more than half died. Any marked deviation from the
usual temperature range in the course of the fever is unfavorable. A
rapid rise of temperature indicates increased danger: it may be due to
the occurrence of a complication or of some other cause acting
unfavorably upon the patient. A sudden and decided fall should excite
even more alarm, as it is generally the consequence of a free
intestinal hemorrhage. A temporary abatement of the fever, with
amelioration of the other symptoms, occurring between the tenth and
twentieth days, and giving rise to the hope that convalescence is
about to commence, but followed by a return of the symptoms in an
aggravated form, is also unfavorable. Such cases, according to Chomel,
Louis, Bartlett, and Murchison, almost invariably terminate fatally.

[Footnote 91: Quoted by Liebermeister.]

The prognosis is bad in cases in which coma or wild or violent
delirium comes on early. A moderate amount of delirium, especially
when it occurs only at night or upon wakening in the morning, and is
readily dissipated by attracting the patient's attention, or stupor
which disappears when he is thoroughly roused, is not unfavorable.
Insomnia, subsultus tendinum, carphologia, slipping down in bed,
incontinence of the urine or feces, and retention of urine, are all
symptoms of bad omen. Rigidity of the limbs is also a bad symptom; Dr.
Jackson reports six cases in which this symptom occurred, only one of
which recovered. Excessive subsultus is especially unfavorable, as it
is generally most marked in cases in which the ulcerations of the
intestines are most extensive. Extreme deafness occurs in mild as well
as severe cases; it is therefore without significance in prognosis.

{316} In estimating the importance, in a prognostic point of view, of
these various nervous symptoms, it is important to bear in mind that a
degree of fever which produces no disturbance of the mental functions
in a phlegmatic person will give rise to active delirium and other
marked cerebral symptoms in a person of an excitable temperament.

A change in the character of the pulse and of the action of the heart
is often the earliest indication of the approach of danger in typhoid
fever, and both pulse and heart should therefore be carefully examined
at every visit. The first change is usually a diminution in the
intensity of the first sound of the heart. This is significant, as it
is frequently the earliest premonition of cardiac failure, to which a
large proportion of the deaths in typhoid fever is due. A pulse of 120
and over, especially if it is at the same time feeble, is also
unfavorable. The important part which the frequency of the pulse plays
in the prognosis is shown by the following observations made by
Liebermeister at the hospital in Basle: Of 63 cases in which the pulse
rose to or above 120, 40 were fatal, or nearly two-thirds. Among these
63 were 37 in which it did not rise to 140; of these, 19 were fatal,
or about one-half; in 26 it rose above 140; of these, 21, or about
four-fifths, were fatal. In 12 patients it rose above 150; of these,
11 died. Of those in which the pulse rose to 160, the only case that
ended in recovery was that of a girl twenty-one years old suffering
from an imperfectly developed typhoid. Intermittence of the pulse is
unfavorable, especially, according to Hayem,[92] when it occurs during
the first week of the disease. In convalescence intermittence is not
to be regarded as an unfavorable symptom. The prognosis is bad also in
those cases in which, with excessive weakness of the pulse, there are
other evidences of cardiac failure, as, for instance, congestion of
the lungs, cyanosis of the surface, coldness of the extremities. A
very frequent pulse is not so unfavorable in a child as in an adult,
or in a person of a nervous temperament as in one of a different
disposition.

[Footnote 92: _Loc. cit._]

Other unfavorable symptoms are a dry, brown tongue, excessive
tympanites with great abdominal tenderness, severe diarrhoea, vomiting
when it occurs late in the disease, intestinal hemorrhage, and
colliquative sweats. The delusion sometimes observed in very severe
cases, in which the patient declares that he is not ill, is a very bad
sign, many authors, and among them Louis, asserting that they have
never known recovery to take place after it has been manifested.
Peritonitis is a very serious complication, whether due to perforation
or to some other cause. Still, it would appear not to be invariably
fatal, since recovery has occurred in cases in which all the symptoms
of this complication were present.

Favorable symptoms, on the other hand, are a gradual decrease of the
temperature with increasing morning remissions, moistening and
cleansing of the tongue, a lessening of the delirium, and other
nervous symptoms, reappearance of an intelligent expression,
recognition by the patient of friends and attendants, and a diminution
of the diarrhoea. A copious eruption is also regarded by many as a
favorable symptom. Cases in which constipation exists generally do
well. Nathan Smith never knew a patient to die whose bowels were
constipated throughout the attack.

The death-rate of typhoid fever is found to vary very considerably in
different years and in the different seasons of the year, as will be
seen {317} from the two following tables. Statistics as to the
mortality of the disease to be reliable must therefore be based upon a
large number of cases extending over a series of years.

The following table shows the number of cases admitted into the
Pennsylvania Hospital during each of the twenty years ending Dec. 31,
1881, and the ratio of mortality among them:

TABLE NO. 1.

 -------+------+------+------+------+--------+--------+-------+-------
        |      |      |      |      |        |        |       |Percen-
        |      |      |      |      |        |        |       |tage of
        |      |      |      |      |        |        |       | deaths
        |      |      |      |      |        |        |       |  after
        |      |      |      |      |        |        |       |deduct-
        |      |      |      |Number|        |        |       |   ing
        |      |      |      |  of  |        |        |       |  cases
        |      |      |      |deaths| Average|        |       |  fatal
        |      |      |      |within|  stay  |        |       | within
        |      |      |      |  48  |in cases|        |       |   48
        |      |Number|Number| hours| ending | Average|       |  hours
        |Number|  of  |  of  |  of  |   in   |  stay  |Percen-|   of
        |  of  |recov-| dea- |admis-| recov- |in fatal|tage of| admis-
  YEAR. |cases.|eries.| ths. | sion.|  ery.  | cases. |deaths.|  sion.
 -------+------+------+------+------+--------+--------+-------+-------
  1862  |  89  |  68  |  21  |   7  | 54-1/3 |  8     |  23.6 |  17.7
  1863  |  36  |  33  |   3  |   2  | 32-1/5 |  3-1/3 |   8.3 |   2.9
  1864  |  43  |  35  |   8  |   1  | 38-1/2 |  8     |  18.6 |  16.3
  1865  |  36  |  31  |   5  |   1  | 38-1/2 |  5-1/2 |  13.9 |  11.4
  1866  |  23  |  17  |   6  |   0  | 45-2/3 |  9     |  26.0 |
  1867  |  24  |  20  |   4  |   0  | 37-1/3 |  6-1/2 |  16.6 |
  1868  |  27  |  23  |   4  |   0  | 44-3/4 | 10     |  14.8 |
  1869  |  21  |  16  |   5  |   1  | 35-1/2 | 14     |  23.8 |  20.0
  1870  |  24  |  19  |   5  |   1  | 47-1/2 | 11     |  20.8 |  17.4
  1871  |  32  |  26  |   6  |   1  | 37-3/4 | 13-1/2 |  18.8 |  15.0
  1872  |  21  |  16  |   5  |   3  | 37-1/2 |  4-1/2 |  23.8 |  11.1
  1873  |  12  |   8  |   4  |   2  | 34     |  9     |  33.3 |  20.0
  1874  |  16  |  12  |   4  |   0  | 54-1/2 |  9-3/4 |  25.0 |
  1875  |  20  |  18  |   2  |   1  | 48     |  4-1/2 |  10.0 |   5.3
  1876  |  30  |  21  |   9  |   2  | 45-1/2 | 11     |  30.0 |  25.0
  1877  |  48  |  34  |  14  |   4  | 48-1/2 | 12-1/2 |  29.2 |  22.7
  1878  |   8  |   5  |   3  |   0  | 49     |  5-2/3 |  37.5 |
  1879  |  17  |  15  |   2  |   0  | 53-1/3 |  8     |  11.8 |
  1880  |  40  |  35  |   5  |   2  | 47     | 10-1/2 |  12.5 |   8.0
  1881  |  54  |  48  |   6  |   0  | 41-3/4 |  8     |  11.1 |
 -------+------+------+------+------+--------+--------+-------+-------
 Totals,| 621  | 500  | 121  |  28  | 43-1/2 |  8-3/4 |  19.5 |  15.7
 -------+------+------+------+------+--------+--------+-------+-------

Out of the 621 cases admitted, 121 were fatal. This gives a death-rate
of 19.5 per cent.; but if we deduct the 28 cases in which the patients
died within forty-eight hours of their admission, it falls to 15.68
per cent., or about the same ratio as Murchison found to exist among
the cases treated at the London Fever Hospital. Other observers have
obtained slightly different results. Thus, the mortality was 11.16 per
cent. in 197 cases analyzed by Dr. Hale, and 13.5 per cent. in 303
cases collected by Dr. James Jackson. Dr. Cayley[93] found the
death-rate of the several hospitals in London to be 17.8 per cent.,
and Geissler[94] that it was in all the German hospitals 12.8 per
cent. in 1877, and 13.5 per cent. in 1878. Flint had 18 deaths in 73
cases, or 24.4 per cent. According to Liebermeister, the ratio of
mortality at the hospital at Basle during the twenty-two years from
1843 to 1864, or before the introduction of a {318} systematic
anti-pyretic treatment, was 27.3 per cent., and only 8.2 per cent.
during the six years immediately following its adoption. As the
results obtained at the Pennsylvania Hospital are apparently not so
favorable as those reported at some of the continental hospitals, it
is only proper to state that a large proportion of the cases were
severe, that many of them were far advanced in the disease when
admitted, and that very few of the patients were under twenty-one
years of age. These are all circumstances which influence very
decidedly the prognosis in typhoid fever. In no other city are the
laboring classes able to surround themselves with so many comforts as
in Philadelphia. This fact, fortunate as it is in the main, often
operates to the disadvantage of the patient by enabling his family to
indulge for a time the reluctance which it naturally feels to part
with a member when sick. In the case of the young this reluctance is
so hard to overcome that children with acute affections are rarely
brought to hospitals for treatment. There were also special causes for
the large mortality in certain years. This was particularly the case
in 1862, when a large number of soldiers fresh from the battlefields
of Virginia, and suffering from the typho-malarial form of the
disease, were admitted into the hospital. Many of them were moribund
upon admission, and others, exhausted by the fatigue incident to
transportation here and by previous hardships, soon succumbed to the
disease.

[Footnote 93: _Med. Times and Gaz._, 1880.]

[Footnote 94: _Schmidt's Jahrbuch_.]

Table 2 gives the number of cases, with the number of deaths occurring
in each season, at the Pennsylvania Hospital during the last twenty
years:

TABLE NO. 2.

  -------------------------+---------+---------+---------+---------
                           | Spring. | Summer. | Autumn. | Winter.
  -------------------------+---------+---------+---------+---------
  Number of cases          |   89    |  259    |  182    |   91
  Recoveries               |   73    |  191    |  163    |   73
  Deaths                   |   16    |   68    |   19    |   18
  Percentage of mortality  |   18.0  |   26.2  |   10.4  |   19.8
  -------------------------+---------+---------+---------+---------

It will be seen from this table that the highest death-rate occurred
in the summer and the lowest in autumn, while there was only a slight
difference between the death-rate of spring and that of winter.
Murchison's experience, based on a much larger number of cases, has
led him to conclude that while the disease is a little less fatal in
autumn, the difference in the mortality at different seasons is very
inconsiderable. Chomel believed that the percentage of deaths was
highest in France during the winter months, and Bartlett held the same
opinion as regards America. Epidemics of great severity have
undoubtedly prevailed in winter, as the in Lowell, Mass., referred to
by Bartlett, but there can be little doubt that the death-rate is
highest in this country during the warm months of the year. Dr.
Cleemann[95] found that the monthly average mortality in Philadelphia
for the ten years from 1866 to 1875 was highest in August, and next
highest in September, confessedly the two months of the year when the
heat in this city is most exhausting. I feel very sure I have lost
patients with typhoid fever in these months {319} and in July who
would probably have recovered if the weather had been cooler. With a
temperature often rising above 90 degrees F. at midday, and sometimes
for several days at a time never falling below 80 degrees, all
radiation of heat from the surface of the body is arrested, and death
frequently occurs as the result of hyperpyrexia.

[Footnote 95: _Transactions of the College of Physicians of
Philadelphia_, 3d S., vols. ii. and iii.]

The stage of the disease at which efficient treatment is begun has a
manifest influence upon the result. This is strikingly shown by some
observations of Jackson: 90 cases were admitted into the Massachusetts
General Hospital during the first week--of these 7 died, or 1 in
12.85; 139 cases were admitted in the second week--of these 16 died,
or 1 in 8.68; 46 cases were admitted in the third week--of these 10
died, or 1 in 4.60; and 21 cases were admitted in the fourth week, and
of these 5 died, or 1 in 4.20. Convalescence also occurred much
earlier in those who were admitted early.

Murchison found that in a large number of cases the death-rate varied
at different ages as follows: Under ten years it was 11.36 per cent.;
from ten to fourteen years it was 12.86 per cent.; from fifteen to
nineteen years it was 15.48 per cent.; from twenty to twenty-nine
years it was 20.46 per cent.; from thirty to thirty-nine years it was
25.90 per cent.; from forty to forty-nine years it was 25 per cent.;
and above fifty years it was 34.94 per cent.

According to Liebermeister, among the 1743 patients treated for
typhoid fever in the hospital at Basle from 1865 to 1870, inclusive,
there were 130 who were more than forty years old; of these 39, or 30
per cent., died, while the mortality among the patients under forty
amounted only to 11.8 per cent. Among the cases of typhoid fever in
individuals over forty years of age collected by Uhle, more than half
proved fatal. According to Friedrich,[96] there were, among 16,084
children treated in the Children's Hospital at Dresden, 275 cases of
typhoid fever, of which 31, or not quite 11 per cent., proved fatal.
Age, therefore, exercises a positive influence upon the mortality of
typhoid fever. Its influence is less decided in this disease than in
typhus, in which the death-rate does not reach 4 per cent. until after
the age of twenty, when it rapidly rises from 12.34 per cent. until it
reaches 57.03 per cent. in patients above fifty years of age. The
comparatively slight mortality of typhoid fever among children is
probably due to the fact that the temperature is less often
continuously high in them than in adults, and that while hyperpyrexia
is frequently present, it is generally better borne and less likely to
produce paralysis of the heart. Liebermeister says that the only case
which he has seen recover after the temperature had repeatedly risen
to 107.5 degrees F. was that of a girl fourteen years of age. It is
also said that the intestinal lesions are not so severe, and the
liability to complications and sequelae less marked, in children.

[Footnote 96: Quoted by Liebermeister.]

Typhoid fever appears to be a slightly more fatal disease in women
than in men, for while in some local epidemics the percentage of
deaths is greater among the latter than among the former, the reverse
is found to be the case when the records of a large hospital for a
number of years are carefully examined. According to Murchison, the
mortality at the London Fever Hospital was about 1 per cent. higher
among the female than among the male patients, and about the same
difference in the death-rate {320} of the two sexes has been reported
by continental physicians. A greater disparity even than this has been
observed by Liebermeister at the hospital at Basle, where the
death-rate for women was 14.8 per cent., and only 12 per cent. for
men. Murchison says that this excess of mortality among the former
cannot be accounted for by the influence of child-bearing upon the
course of the fever, since it is much more decided between the ages of
five and fifteen than in the period of child-bearing.

The rich are not only as liable to contract typhoid fever as the poor,
but the disease is also quite as fatal among them. Murchison found
from the statistics of the London Fever Hospital that the mortality is
not greater among the destitute than among the better class of
patients, and expresses the opinion that in private practice enteric
fever is probably more fatal among the upper classes than among the
very poor. Chomel and Forget seem to have reached a similar
conclusion.

All authors agree that the prognosis is unfavorable in corpulent
persons, not only on account of the diminished power of resistance to
disease generally which such persons exhibit, but also because the
febrile movement is often intense in them, and the degenerative
changes of the muscles and organs of the body which it induces are
generally early developed and of high grade. Liebermeister goes so far
as to say that even in the case of ill-nourished, anaemic, or
chlorotic individuals the chances for life are better than in the
corpulent. Murchison has also expressed the opinion that a large,
muscular development is likewise an unfavorable element in prognosis,
having seen the strong and robust succumb to the disease oftener than
the feeble. The mortality from the disease appears to be greater in
certain families than in others. This has been ascribed by some
writers to peculiarities of constitution, but it may be due to other
causes, as, for instance, difference in the intensity of the poison.
The disease is also often very fatal among the intemperate, who
usually bear the disease badly in consequence of the presence of
various degenerations of one or more of the important organs of the
body caused by the excessive indulgence in alcoholic stimulants;
paralysis of the heart being not an infrequent cause of death among
them.

Certain epidemics have been exceedingly fatal, while in others the
percentage of deaths has been very small. There can be no doubt that
in most of these cases there has been a difference in the virulence of
the poison. Recent residence in an infected locality has been shown by
Murchison and other writers to have a decided influence in increasing
the fatality of the disease. Second attacks are, on the other hand,
usually mild. Some diversity of opinion exists among authors in regard
to the effect that pregnancy has upon the course of the disease.
Murchison believes that it is a far less formidable complication than
is usually thought, while Liebermeister, on the contrary, holds a
directly opposite opinion. He also regards the prognosis as
unfavorable when the disease occurs in childbed or a short time
afterward. Individuals with disease of the heart, emphysema, or
bronchial catarrh who contract typhoid fever are said to be more
liable to paralysis of the heart than others, hence the existence of
these diseases materially diminishes their chances of recovery.

TREATMENT.--Inasmuch as the spread and propagation of typhoid fever
may be prevented to a great extent, if not entirely, by the {321}
employment of judicious sanitary measures, it is proper, before
entering upon the discussion of its curative treatment, to devote a
few words to the prophylaxis of the disease.

Whether the physician accepts the theory so ably advocated by
Murchison, that typhoid fever may arise from exposure to the products
of the fermentation of healthy feces, or adopts the view now held by a
large number of investigators, that the disease is never generated in
the absence of the specific germ, he will admit the great importance
of an efficient system of sewerage, with a thorough flushing of the
sewers at regular and frequent intervals, for disposing of the fecal
discharges of the population of all towns, no matter how
inconsiderable in size. No less important is it that the drains of
every dwelling should be well constructed and kept in good order. They
should be trapped just before they empty into the sewer, and should be
provided with the means of thorough ventilation between the trap and
the walls of the house by a free communication with the outer air. The
soil-pipe should be carried up three or four feet above the top of the
house, and every water-closet, bath-tub, stationary washstand, and
sink should have its own separate trap, and none of them should be
placed in rooms unprovided with a window or with some other sufficient
means of ventilation. Physicians should, as sanitarians, urge upon the
authorities of all cities and towns the importance of deriving their
water-supply from a source unpolluted by sewerage or by any other
substances likely to be deleterious to health. They should also see
that when water is stored in a tank inside of a house the overflow
pipe does not communicate directly with the drain, since if this is
allowed to occur the water may very soon become contaminated with
sewer gas, and consequently unfit for internal use.

In the case of isolated country-houses and of small villages some
other means of disposing of the fecal discharges of the inhabitants
than by sewers has to be found. In the great majority of instances no
better way presents itself than by the ordinary cesspool. Care should,
however, be taken that this is so constructed and situated that there
can be no filtration of its contents into wells from which water for
drinking is obtained.

As the alvine dejections of the sick are beyond question the medium by
which typhoid fever is most frequently communicated to others, the
importance of thoroughly disinfecting them before they have acquired
the power of imparting the disease cannot well be overestimated.
Liebermeister recommends that the bottom of the bed-pan should be
strewed, each time before being used, with a layer of sulphate of
iron, and that immediately after a passage crude muriatic acid should
be poured over the fecal mass, as much as one-third or one-half of the
bulk of the latter being used. He also urges, whenever it is
practicable, that the contents of the bed-pan should be emptied into
trenches dug anew every two days and filled up when discarded, care
being of course taken that they are not located anywhere in the
vicinity of wells. Murchison seems to prefer carbolic acid to other
chemical agents as a means of preventing fecal fermentation. For this
purpose the liquid carbolic acid may be diluted with water in the
proportion of 1 to 40 to 1 to 20, or it may be mixed with sand or
sawdust. I have myself employed as a disinfectant with success the
solution of the chlorides sold under the name of Platt's chlorides. As
the discharges must in cities, in the great majority of instances, be
emptied into {322} water-closets, these should be freely flushed with
water after every time they are used; and it is well to impress upon
the attendant on the sick the importance of doing this. The bed-linen
of the patient and his clothes, if they are soiled by his discharges,
should be removed as soon as possible, and subjected to a high degree
of heat (248 degrees F.) or soaked in a solution of the chlorides or
of carbolic acid for several hours before being washed. If these
precautions are observed, cases of typhoid fever may be treated in the
wards of general hospitals without danger to the other patients.

In the doubt and obscurity which generally envelop the diagnosis of
the disease when the physician is first called upon to treat it, it is
impossible to lay down any positive rules for the management of
typhoid fever at its commencement. But even in those cases which begin
insidiously, if the patient is carefully examined enough of the early
symptoms of typhoid fever will be detected to put the physician on his
guard. The thermometer will show the existence of fever, which has a
tendency to increase at night. There will generally be found to be a
little diarrhoea, or at least an increased susceptibility to the
action of purgative medicines; perhaps a little tympany and tenderness
in the right iliac fossa, and moreover a prostration which is out of
all proportion to the other symptoms.

These symptoms, it is true, are not infrequent concomitants of many
diseases besides the one under consideration; but when their presence
cannot be otherwise satisfactorily explained, especially if they have
continued for several days, it is a safe rule in practice to regard
the case as one of typhoid fever, and to regulate the treatment
accordingly. The patient must be put to bed at once, and not allowed
to leave it on any pretext, not even to empty his bladder, after the
first week. This is a rule which should be rigidly enforced in every
case, no matter how mild the symptoms may be. Its non-observance,
either through the neglect of the physician or the ignorance or
wilfulness of the patient, has been the cause of some disastrous
results; in illustration of which it is only necessary to refer to the
frequency with which perforation of the bowel occurs in walking cases
of typhoid fever. Perfect quiet should be maintained in the sick room.
Visitors should be excluded from it, and the attendants limited in
number to those actually necessary to carry out the directions of the
physician. All unnecessary talking is to be avoided, and especially
conversation carried on in a low tone of voice, which is always
annoying to the sick.

There is only one condition under which I should be disposed to break
the rule of absolute quiet and rest laid down above, and that is when
called upon to treat typhoid fever in the built-up portion of our
large cities during the summer season. If the patient were still in
the first week of the disease, if his circumstances were sufficiently
affluent to enable him to surround himself with every comfort, and if
it did not involve a journey of more than a few hours, I should
unhesitatingly send him to the sea-coast. I have so often seen cases
prove fatal in summer in consequence of the great heat of the city--a
heat, too, which is sometimes almost as great at night as in the
day-time--that I should feel that I was giving him an additional
chance of life by sending him where the heat was, at least
occasionally, tempered by cool breezes from the ocean. During the late
war numbers of soldiers were frequently sent in the early stages of
{323} typhoid fever from the camps in the South to their homes or
hospitals in the North, and it is fair to say that they did at least
as well as those who remained behind. But when the journey may be
accomplished by means of Pullman cars and the other appliances of
modern travel the risk, and even discomfort, it involves to the
patient is reduced to the minimum.

As the disease is usually one of long duration, the patient being
rarely able to leave his bed under four weeks, and more frequently
being obliged to keep it for a much longer time, the sick room should,
wherever practicable, be large, airy, and provided with an open
fireplace, which is a much more efficient means of securing thorough
ventilation than an open window, while it is not liable to the
objection sometimes applicable to the latter of causing a direct
draught upon the patient. It is well, however, for the physician to
remember that the danger from this source is very much exaggerated by
the laity, and that patients in the febrile stage of typhoid fever do
not readily take cold. Still, the same end may generally be attained
without the least risk to the patient by opening a window in an
adjoining room. The temperature of the sick room should be steadily
maintained at between 65 degrees and 68 degrees F.

The careful regulation of the diet is also a point of great importance
in the management of typhoid fever; for in this disease there are not
merely the high fever and other exhausting symptoms, speedily inducing
excessive prostration, loss of strength, and emaciation, common to
many fevers, but there is also the peculiar ulceration of the bowels,
which gives rise to danger of its own and demands special
consideration in treatment. The food must therefore be not only
nourishing, but also readily digestible, and not likely to create
irritation in its passage through the intestines. All solid food
should therefore be excluded from the dietary of the patient as long
as the fever lasts. Indeed, it is better to continue this prohibition
even after the subsidence of the fever if rose-colored spots are still
to be seen on the abdomen or elsewhere, or if there exists a tendency
to diarrhoea or any other symptom indicating that the disease has not
fully run its course. Having myself seen some rather disastrous
results from a too early return to solid food, I have been accustomed
in my own practice to interdict its use until at least two weeks after
the beginning of convalescence. Jaccoud also lays much stress upon
this point, saying that the early administration of meat always gives
rise to fever, to which, from its cause, he gives the name of febris
carnis. On the other hand, Flint[97] and Peabody have recently
advocated the giving of solid food immediately after the cessation of
fever, in the belief that recovery is thereby promoted. Milk as an
article of diet is unquestionably to be preferred to all others in
typhoid fever. It is open, it is true, to the objection of
occasionally forming tough curds in the stomach, but this may
generally be prevented by giving the milk in small quantities at a
time, diluted with lime-water or barley-water or mixed with some
farinaceous substance. No positive general rule can be laid down as to
the amount to be given. This will be found to vary not only in
different cases, but also in the same case at different times. Indeed,
in those cases which begin abruptly with symptoms of gastro-intestinal
irritation, if it is forced upon the patient in large quantities it is
not only usually rejected, but also causes an aggravation of the
symptoms, while after {324} this irritation is allayed it will be
digested without difficulty. As a general rule, most adult patients
will be able to take from a quart and a half to two quarts of milk
daily, given in quantities of from four to six ounces every two or
three hours. It should be remembered, however, that if more is taken
than can be assimilated it will act as an irritant and increase the
diarrhoea. If, therefore, the stools contain undigested milk, the
quantity should be diminished. Patients are occasionally met with, but
not in as great number as is often asserted, with whom milk habitually
disagrees. In these cases it must of course be replaced in whole or in
part by some other article of food. Under these circumstances some one
of the liquid preparations of beef may be given with advantage,
although it may be objected to them also that they sometimes occasion
an increase of diarrhoea. Beef-tea or beef-essence, made from the
fresh meat whenever this can be obtained, is to be preferred to all
others; but when it cannot, that made from the preparations of
Johnston or Brand is the best substitute. When the stomach is very
irritable, Valentine's meat-juice, in consequence of the smaller bulk
in which it is given, often answers an admirable purpose.

[Footnote 97: _Medical News_, Mch. 29 and Apl. 5, 1884.]

Various farinaceous substances, such as farina, corn-starch, and
arrowroot, are also occasionally given in typhoid fever, and, although
the last named would seem to be indicated in cases in which diarrhoea
is a prominent symptom, their tendency to cause flatulence is so great
that their use in the acute stage of the fever has not found favor
among physicians generally. In convalescence, on the other hand, they
are generally perfectly well borne.

The subject of the administration of alcoholic stimulants in typhoid
fever may be conveniently considered in this connection. Some
difference of opinion exists in regard to the quantity in which they
should be given, and indeed in regard to the necessity for their use
at all in many cases, as, for instance, in those of young persons
whose health and habits had been good previously to the attack. I have
myself treated several such cases without alcohol, and have not been
able to perceive that their duration was longer and the result less
favorable than in cases in which it was given in the usual amount. It
is, moreover, not necessary to prescribe it always, even in very
severe cases, at the beginning of an attack. When given at this time,
it not infrequently does harm by increasing the fever. It should be
reserved, therefore, until the action of the heart grows feeble and
the first sound becomes indistinct. It is not possible to lay down any
general rule as to the amount to be given, even in severe attacks.
This will vary in different cases, and to a certain extent will be
determined by the effects it produces. If the pulse grows stronger and
the delirium diminishes under its use, it is doing good and should be
continued; if, on the other hand, there is increase of delirium and
restlessness, the quantity should be diminished.

In cases in which only a gentle stimulus is required wine in the form
of wine-whey will often be found to meet the indication fully.
Generally, however, it will be necessary to have recourse to whiskey
or brandy. The choice between these may usually be left to the
patient's fancy; brandy is, however, to be preferred in cases in which
diarrhoea is a prominent symptom. These stimulants should be given in
small quantities frequently repeated. In many cases a dessertspoonful
every two or three hours, {325} either diluted with water or, when the
stomach is irritable, with carbonic acid water or given in the form of
milk punch, will be sufficient. In others a tablespoonful every two
hours, or even at shorter intervals, will be required, but it will
rarely be necessary to exceed eight ounces a day for more than a few
days at a time.

Although the physician will not often be called upon at the present
day to encounter and combat the prejudice so common formerly against
the free administration of water in the febrile condition, he will
frequently find nurses and others not sufficiently alive to the
importance of supplying it when the patient, having fallen into the
typhoid state, ceases to ask for it. The high temperature which is
generally present in this condition, and the rapid combustion of
tissue which it causes, make a full supply of liquid an urgent
necessity which it is dangerous to disregard. Water is the best of all
diuretics, and it is important in this disease, as indeed it is in
many others, that the functions of the kidneys should be kept active,
so that the products of the combustion of the tissues may be
eliminated with their secretion. Care, however, should of course be
taken, as pointed out by Da Costa,[98] that water is not given in such
quantity that the desire for and capability of digesting food is
destroyed by it.

[Footnote 98: Preface to Wilson's _Treatise on the Continued Fevers_.]

In the few cases which begin abruptly with symptoms simulating those
of a so-called bilious attack the practitioner will usually content
himself with the administration of medicines calculated to allay the
irritability of the stomach and bowels. For this purpose I have found
the bicarbonate of potassa in solution, to which lemon-juice is added
at the moment it is taken, so as to produce an extemporaneous
effervescing draught, often an admirable remedy. In other cases I have
used with advantage small doses of calomel or blue mass, followed, if
necessary, by a gentle saline purge. When the symptoms have occurred
soon after a hearty meal, or when there is evidence that the stomach
is overloaded, it will occasionally be necessary to have recourse to
an emetic. Usually, the indications for treatment at the beginning of
an attack are much less definite, and even in the class of cases just
referred to they become so after the subsidence of the
gastro-intestinal symptoms. Indeed, the treatment in the larger number
of cases must be purely symptomatic until the nature of the disease
has fully declared itself. The presence of fever will suggest the use
of the neutral mixture, effervescing draught, or spirit of Mindererus,
combined, if there is decided tendency to evening exacerbations, with
sulphate of quinia in full doses. If there is much diarrhoea, Hope's
camphor mixture or opium in some other form may be given; if delirium
is a prominent symptom, ice or cloths wrung out of cold water should
be kept constantly applied to the head.

But even after all doubt in regard to the diagnosis has been dispelled
and the existence of typhoid fever has been recognized, the treatment
most in favor with physicians is in large measure symptomatic in
character. It is true that various specific treatments, to which
fuller reference will be made hereafter, have been lately proposed,
but the results obtained by them up to the present time where they
have been fairly tested are not so favorable as to induce the body of
the profession to adopt them to the exclusion of all other methods. It
is certain that no remedy or plan of {326} treatment has yet been
discovered which has the power of cutting the disease short, although
this power has been claimed at different times for several. Thus, at
one time quinia in very large doses was believed to possess it, at
another venesection, and at another cold baths. But experience has
shown that these and other perturbating remedies often do harm, and
there is good reason to believe that the apparent good which has
followed their use in a comparatively small number of instances may be
better explained by supposing that an error of diagnosis has been made
than by attributing to them the power of arresting the progress of the
disease. Medicines are, however, by no means useless in the treatment
of typhoid fever. There is no question that the disease is not only
generally conducted to a favorable issue, but that its duration is
often materially shortened, by their judicious use. It is evident,
however, that the treatment must vary with the severity of the attack.
In a few cases it is scarcely necessary to interfere with the course
of the disease by the administration of medicines. In others, on the
contrary, it is necessary to act promptly and energetically in order
to save life.

When called upon to treat typhoid fever, if the case is a mild one
with no bad symptoms, such as excessive diarrhoea, delirium, tremors,
and the like, and especially if the temperature does not rise higher
than 102 degrees F., I am accustomed, after giving minute directions
as to the diet and general care of the patient, to prescribe from two
to three grains of sulphate of quinia four times daily. No great power
in reducing the temperature of the body can, of course, be claimed for
these doses, but experience has shown that the impression which they
make is useful, and they do not interfere with the administration of
the drug in larger quantities should this become necessary. Their
action, too, is tonic, and, as they rarely produce cinchonism, the
objection often made to the use of larger doses does not apply to
them. I am also in the habit of adding to each dose of quinia from ten
to fifteen drops of one of the mineral acids. These acids were
originally prescribed in typhoid fever under the impression that they
neutralized the cause of the disease, which was supposed to be an
alkaline poison. Although the results of recent research, which tend
to show that the cause of the disease is an organized germ, give no
support to this theory, they continue to be used by a large number of
physicians of experience. I do not know that any satisfactory
explanation of their action in typhoid fever has ever been given. They
are certainly tonics, and are therefore indicated, if not in the
beginning of the disease, as soon as the strength begins to fail. If,
as the disease progresses, the tongue becomes dry and fissured, and if
there is much tympany, it will be well to give, in addition to the
quinia, ten drops of the oil of turpentine in mucilage every two
hours. This was a favorite remedy of the late George B. Wood, the
distinguished professor of the Theory and Practice of Medicine in the
University of Pennsylvania, who attributed the improvement in the
symptoms which generally follows its use to a direct influence of this
medicine upon the ulcers in the intestines. Although inclined to
believe that the correct explanation of this improvement is its
stimulating action upon the circulation and secretions, I fully agree
with him in regard to its usefulness in many cases. Under its use I
have often seen the dry, fissured, and shrivelled tongue {327} grow
moist and throw off its coating much earlier than in all probability
it would otherwise have done.

No other than this simple treatment is required in a large number of
cases, but even in mild cases symptoms occasionally arise which render
necessary some modification of it. It will, however, be more
convenient to postpone the discussion of this part of the treatment of
typhoid fever until after the treatment of the more serious forms of
the disease has been considered.

When typhoid fever assumes a severe type, the success of the physician
in the management of the disease will depend largely upon the
readiness with which he detects indications for treatment and the
promptness with which he meets them. Usually, one of the first
symptoms to demand attention is the high temperature. This is not only
an early symptom in many bad cases, but may continue throughout the
attack; or it may suddenly supervene in cases in which the fever has
previously been moderate in degree, and when excessive may be the
direct or indirect cause of death. The reduction of the temperature is
therefore an indication the importance of which cannot well be
overestimated. Fortunately, there are several methods by which this
end may be accomplished. It will, however, be necessary for our
purpose to consider only two of them in detail: 1, the cold-water
treatment; 2, sulphate of quinia in full doses.

The cold-water treatment is not new, since it was practised in the
form of cold effusion in the treatment of fevers as long ago as 1787
by Currie of Liverpool, who may be said to have introduced it, and who
asserted that it had the power not merely of moderating the symptoms
of these diseases, but also, in many cases, of cutting them short. It
enjoyed at first a high degree of popularity, which lasted for from
twenty to thirty years, but finally fell into disuse, probably in
consequence of the exaggerated character of the claims which were made
for it by its advocates. Although resorted to from time to time in
various parts of the world, the merit of having brought it again into
notice seems to be due to Brand of Stettin, who published a work on
_The Hydrotherapy of Typhoid Fever_ in 1861. Still more recently, the
recorded observations of Bartels, Jurgensen, Ziemssen, and
Liebermeister in Germany, and of Wilson Fox and others in England,
have so far restored the treatment to professional favor that there
are few physicians either in this country or abroad who do not
occasionally have recourse to it.

The cold-water treatment may be applied in several different ways: 1,
the cold bath; 2, the graduated bath; 3, cold affusions; 4, the cold
pack; 5, cold sponging; 6, cold compresses; and 7, frictions with ice.
They all act in the same manner, and depend for their efficacy upon
their power of abstracting heat from the body, and are useful just in
proportion as they do this. There is no reason for believing that they
have the power to modify the conditions upon which the production of
heat depends, but there is, on the other hand, no doubt that under
their use distressing and dangerous symptoms, such as coma, stupor,
subsultus, and the like, are often much relieved. They probably act,
therefore, by diminishing the metamorphosis of the tissues, and the
consequent loading of the blood with excrementitious products which
the hyperpyrexia has a tendency to promote.

The cold bath is the most effective of all the methods of applying the
{328} cold-water treatment. Liebermeister recommends that the bath for
an adult should be at the temperature of 68 degrees F., and its
duration should be about ten minutes; if, however, the patient shows
signs of great weakness, it should not exceed seven. After the bath he
should be wrapped up in a dry sheet or light blanket and put back in
bed. If the pulse should then show signs of failing, or if there
should be shivering or any other evidence of weakness, he should be
given a glass of wine or brandy or a dose of some other diffusible
stimulus, and bottles containing hot water should be applied to his
feet. The process of cooling goes on for some time after the patient's
removal from the bath, for while a thermometer placed in the axilla
will show that the external temperature is immediately affected by it,
the same instrument placed in the rectum will indicate a gradual fall,
which will continue in many cases for at least half an hour. Shortly
after this the temperature will be observed to rise, and in many cases
it will not be more than two hours before it has attained its former
height. Liebermeister therefore recommends that the thermometer should
be frequently used, and that the baths should be repeated as often as
the temperature rises to 103 degrees F. or above it. He has himself
given them as often as every two hours, or as many as two hundred
during an entire illness, but usually finds that not more than six or
eight a day are required. It often requires some persuasion to
overcome the repugnance which most patients feel at first for these
baths, and the shock of being suddenly immersed in cold water is
agreeable to very few. Later, this repugnance, he says, entirely
disappears. Intestinal hemorrhage, perforation of the bowel, and great
weakness of the heart's action are all contraindications to the use of
the cold bath. They are especially to be avoided, according to
Liebermeister, when the force of the circulation is so far reduced
that the surface of the body is cold while the interior is very hot.
On the other hand, the advocates of this plan of treatment contend
that the existence of pneumonia or of hypostatic congestion of the
lungs is not a sufficient reason for abandoning it, the congestion
often disappearing under its use.

The graduated bath possesses some advantages over the cold bath, as
its use involves less of a shock to the system. It is therefore more
suitable than the latter for nervous and excitable patients, for
persons of advanced age or of general feebleness of constitution, or
for very young children. In it the temperature of the water, which at
the time of the immersion of the patient should be at or above 95
degrees F., is cooled by the gradual addition of cold water until it
is reduced to 72 degrees, or below this point. These baths, to produce
the same effect as the cold baths, must be of longer duration. They
are contraindicated in the same conditions as the latter, but to a
less degree.

Although fully willing to admit the good effects of the cold bath in
many cases, having been, of course, myself a witness of them, I am
indisposed to have recourse to it except in cases of hyperpyrexia of
such intensity that death seems imminent and only to be averted by
energetic treatment, or in cases in which other antipyretic remedies
have failed to reduce the temperature; and for the following reasons:
1. In the first place, it is generally possible to produce a decided
effect by the other methods of applying the cold-water treatment, with
much less discomfort to the patient. 2. In a private house it is not
always practicable to have {329} a bath brought to the bedside of the
patient, and in a general hospital to do so often would occasion a
good deal of annoyance to the other patients in the same ward, and I
have seen ill result from carrying him some distance to the bathroom.
But even where the bath is brought directly to his bedside, it
involves so much movement, and is sometimes the cause of so much
excitement, that its good effects are more than neutralized by its
bad.

Cold affusions, while not nearly so efficacious in reducing the
temperature of the body as the cold bath, are open to many of the
objections which may be urged against the latter mode of treatment.
They are, therefore, rarely employed at the present time.
Liebermeister, however, thinks that they may sometimes be resorted to
with good effect for their brisk stimulating effect on the psychical
functions or the respiration.

The cold pack possesses the advantage over the cold bath and cold
affusions of involving less movement on the part of the patient and of
being less terrifying to children, and may therefore be resorted to in
cases in which the latter method of applying the cold-water treatment
is contraindicated, as, for instance, in persons of feeble
circulation. It is, however, inferior to either of them in its cooling
effects, and must be longer applied to produce the same effect.
Liebermeister estimates that a course of four consecutive packs, of
from ten to twenty minutes' duration apiece, is about equivalent in
effect to a cold bath of ten minutes.

Cold sponging is assigned a very low place among the methods of
abstracting heat from the body by many writers. It has, however, often
been in my hands of much service, and its easy application and the
comfort which patients derive from it are certainly strong
recommendations in its favor. I have employed it frequently in cases
of intestinal hemorrhage, and even in cases of great debility, and
have never yet had any reason to repent my having done so. The
addition of a little vinegar to the water has seemed to me to increase
the effect of the sponging.

Cold compresses, either in the form of cloths wet with cold water or
bladders filled with ice, can only produce a local fall of
temperature, and therefore, except when applied to the head, can be of
little service.

Frictions with ice are a powerful means of depressing the temperature
of the body, and may therefore be resorted to in cases of intense
hyperpyrexia when for some reason the cold bath cannot be obtained,
and when there are no contraindications to the latter.

Liebermeister classes cold drinks, the internal administration of ice,
and the injection of cold water among the means of cooling the body in
fevers; but it is doubtful if any great reduction of temperature can
be brought about by any of these remedies in the quantities in which
it would be safe to use them. The first two, and to a less extent the
last, meet a very important indication, that of supplying water to the
system. Their free use, therefore, forms a very important part of the
treatment of typhoid fever.

Luton of Rheims[99] extols the Diaeta hydrica in the treatment of
typhoid fever. The patient receives absolutely nothing else to drink
but water, which is given in large quantities, for from four to six
days. No nourishment is given until the beginning of the third week,
and first of all milk. If fever returns, the water is given again.
Medicines such as {330} quinia and eucalyptus are given in adynamic
conditions, which Luton says are rare under this treatment. He
believes that the increase of the typhoid germs is prevented by
absolute diet and abundant supply of water.

[Footnote 99: _Journal de therapie_, Oct., 1880.]

Quinia to produce a decided antipyretic effect must be given in large
quantities. Murchison says that a dose of from fifteen to twenty
grains causes within an hour or two a fall of the temperature, and, to
a less extent, of the pulse, which may last from twelve to eighteen
hours, and that he has never known any other disagreeable symptoms
result from its use than noises in the ears, temporary acceleration
and irregularity of the respiration, and occasional vomiting. This
quantity will often, however, be found to be insufficient to produce a
notable reduction of the fever, and it is therefore necessary
occasionally to increase it. Liebermeister usually gives to adults
from twenty-two to forty-five grains of the sulphate or the muriate of
quinia, and this dose must positively be taken within the space of
half an hour, or, at the most, an hour, as it is useless, he says, to
expect the full benefit of this dose to appear if the dose is divided
and its administration is extended over a longer time. He never
repeats it in less than twenty-four hours, and, as a rule, does not
give it again under two days. Jurgensen has exceeded the dose of
forty-five grains without observing any bad effects from it. When
these large doses are taken the fall of the temperature usually begins
a few hours after the administration of the medicine, the minimum
being reached in from six to twelve hours, and it is usually not until
the second day that the temperature attains its former height. It is
found in practice that the most decided results are obtained when the
medicine is given in the evening, so that the time of its fullest
antipyretic effects will coincide with that of the morning remission.
When these large doses produce vomiting, as they occasionally will,
the quinia must be given by the rectum or hypodermically.

Quinia possesses the great advantage over the cold bath that it may be
given in conditions in which it would be dangerous to resort to the
latter. The existence of great cardiac weakness, of perforation of the
bowel, or of intestinal hemorrhage do not usually constitute
contraindications to its use. In my own practice I have not often
found it necessary to have recourse to much larger doses than those
recommended by Murchison, preferring to repeat them if necessary
rather than to give a single dose of even half a drachm.

It will be well, in this connection, to allude briefly to a few other
remedies which have been given for their antipyretic effect. One of
these is digitalis, which has been administered for this purpose in
very large doses. Thus, Liebermeister recommends that from eleven to
twenty-two grains should be given in the course of thirty-six hours. I
have never used this drug in these doses, and therefore cannot speak
of its effects from personal knowledge of them. I have frequently had
recourse to it, however, in more moderate doses, and I think with
advantage.

Another is sodium salicylate. This remedy has been used largely in
England and Germany, and to a less extent in this country. It has been
claimed for it that it has the power of destroying the germs of
typhoid fever, but Stricker[100] finds it difficult to accord it this
property in the face {331} of the fact that he has had three cases of
typhoid fever under his observation which occurred in patients just
recovered from rheumatism, which had been treated by this drug. My own
experience with it in the treatment of this disease is small, but has
been unsatisfactory. While it is undoubtedly an antipyretic, the pulse
becomes weak and the inspiration less strong under its use. The brain
symptoms do not diminish under its use. Indeed, it is said to produce
narcotism in some cases. Dr. Jahn[101] and Dr. Jh. Platzer[102] speak
more favorably of it, but admit that its administration is
occasionally attended by the inconveniences above referred to. The
verdict of the profession in regard to it, tersely expressed by one
who had given it a fair trial, appears to be that it is a remedy that
brings nothing but disappointment to the physician and disaster to the
patient.

[Footnote 100: _Deutsche Milit.-arztl Zeitsch._, 1877.]

[Footnote 101: _Deutsches Arch. f. klin. Med._, 1877.]

[Footnote 102: _Bayr. Arztl. Intell. Bl._, 1877.]

Eucalyptus, in the form of the tincture, is also a favorite remedy
with many practitioners. Dr. Benj. Bell[103] is in the habit of giving
a teaspoonful every three or four hours in a wineglass of water, and
asserts that it diminishes the tendency to diarrhoea and the duration
of the illness.

[Footnote 103: _Edin. Med. Jour._, Aug., 1881.]

The different varieties of typhoid fever require slight modifications
only of the treatment laid down above. In the typho-malarial form,
especially in those cases in which the malarial element predominates,
and in which there is a marked tendency to remission, the early
administration of quinia in full antiperiodic doses is urgently called
for. In some cases which he had the opportunity of observing in the
army, A. L. Cox[104] found great advantage from the use of arsenious
acid in rather large doses. When the disease attacks elderly people,
an early resort to alcoholic stimulants is usually necessary, in
consequence of the excessive prostration it induces in them. Henoch
and Steffen[105] assert that cold baths are not so well borne in
children as in adults. Their influence is transitory only, and their
use has sometimes been followed by fatal collapse. In the renal form
dry, and in some cases cut, cups should be applied externally and
saline diuretics given internally.

[Footnote 104: _Outlines of the Chief Camp Diseases of the United
States Armies_, by Joseph Janvier Woodward, M.D., Philada., 1863.]

[Footnote 105: _Jahrb. f. Korhde_, 1880.]

SYMPTOMS REQUIRING SPECIAL TREATMENT.--Vomiting, when it occurs early
in the disease, is usually checked by the administration of an emetic
and by the application of sinapisms to the epigastrium. The use of
emetics is no longer advisable when it occurs after the first week. It
is better then to trust to small doses of hydrocyanic or carbolic
acid, aromatic spirit of ammonia, or bismuth. It will often be found
that lime-water and milk will remain upon the stomach when every other
article of food or medicine is rejected. In some severe cases which
have been under my care the symptom was permanently relieved by the
frequent administration of small quantities of brandy in iced
soda-water. When vomiting is a consequence of peritonitis it usually
resists every form of treatment.

Diarrhoea, if the number of the stools does not exceed two or three in
the course of twenty-four hours, does not need special treatment.
When, however, it is more severe, prompt measures should be taken to
check it. Under these circumstances laudanum injections have seemed to
me to be {332} by far the best remedy. It is not necessary that these
injections should always contain a large amount of laudanum or that
they should be repeated frequently. In many cases twenty drops once a
day will be found to be sufficient, and it is rarely necessary to
exceed forty drops twice daily. Opium given by the mouth or in
suppository in equivalent quantity does not act with anything like the
same efficacy. If the laudanum injections fail to restrain the
diarrhoea, it will be well to have recourse, in combination with
opium, to the subnitrate of bismuth or the acetate of lead. Nitrate of
silver was at one time much employed in the treatment of typhoid
fever, especially by the late J. K. Mitchell of this city, but was
afterward suffered to fall into neglect. Its use has been recently, to
a certain extent, revived in consequence of the recommendation of
William Pepper,[106] who claims for it the power of modifying the
course of the disease. I have given it in a number of cases, but have
never been able to satisfy myself that it possessed this power. I have
therefore ceased to prescribe it except in the later stages of the
disease, when the symptoms indicate that the intestinal ulcers are in
an atonic condition. Under these circumstances it has appeared to me
to promote their cicatrization. It is important, however, to remember
that diarrhoea is occasionally caused and kept up by more food being
given to the patient than he can assimilate, and it is therefore a
good rule to examine the stools from time to time to see whether they
contain curds of milk or other undigested food. If such is found to be
the case, the amount of nourishment should be diminished, and